Provider Demographics
NPI:1902813140
Name:GREEN, MICHAEL S (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:S
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 1:915 UNION ST.
Mailing Address - Street 2:SUITE 4, EASTERN MAINE HEALTHCARE MALL
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401
Mailing Address - Country:US
Mailing Address - Phone:207-973-8030
Mailing Address - Fax:207-973-6005
Practice Address - Street 1:915 UNION ST
Practice Address - Street 2:SUITE 4, EASTERN MAINE HEALTHCARE MALL
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401
Practice Address - Country:US
Practice Address - Phone:207-973-8030
Practice Address - Fax:207-973-6005
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME015688207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME010211501Medicaid
MEE04605Medicare UPIN
ME010211501Medicaid
MEMM9453Medicare ID - Type Unspecified