Provider Demographics
NPI:1871806315
Name:GREEN, GEARIN A (MD)
Entity type:Individual
Prefix:
First Name:GEARIN
Middle Name:A
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 NEENAH CTR
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-3070
Mailing Address - Country:US
Mailing Address - Phone:920-830-5900
Mailing Address - Fax:920-830-5910
Practice Address - Street 1:2400 E CAPITOL DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-8728
Practice Address - Country:US
Practice Address - Phone:920-831-5050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-26
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT211866207X00000X
CAA149777207X00000X
WI73593207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1871806315Medicaid