Basic Information
| Provider Information | |||||||||
| NPI: | 1972519916 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | BONNIE | ||||||||
| MiddleName: | GRAHAM | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 142 S RICE ST | ||||||||
| Address2: | |||||||||
| City: | BREVARD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287123722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8288835550 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 147 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BREVARD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287124617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8288847546 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 01/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 201402140 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.