Basic Information
| Provider Information | |||||||||
| NPI: | 1740288380 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9 | ||||||||
| Address2: | |||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376620009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238572066 | ||||||||
| FaxNumber: | 4238572070 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 MEDICAL PARK BLVD | ||||||||
| Address2: | SUITE 450W | ||||||||
| City: | BRISTOL | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376207430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239683713 | ||||||||
| FaxNumber: | 4239687352 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2005 | ||||||||
| LastUpdateDate: | 06/11/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 011243 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3037795 | 01 | TN | BLUE CROSS | OTHER | 014531 | 01 | VA | ANTHEM | OTHER | 6093752 | 05 | VA | MEDICAID |