Provider Demographics
NPI:1447359054
Name:GREEN, MICHAEL D (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:632 PLANK RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:CLIFTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12065-2019
Mailing Address - Country:US
Mailing Address - Phone:518-373-2121
Mailing Address - Fax:518-373-1762
Practice Address - Street 1:3 EMMA LN
Practice Address - Street 2:
Practice Address - City:CLIFTON PARK
Practice Address - State:NY
Practice Address - Zip Code:12065-3763
Practice Address - Country:US
Practice Address - Phone:518-373-8270
Practice Address - Fax:518-373-8235
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2014-02-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY120848-12085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY55197BMedicare PIN
NYD96968Medicare UPIN
NYRA0369Medicare PIN
NYCC0828Medicare PIN