Provider Demographics
NPI:1356384226
Name:GREEN, MICHAEL RICHARD (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:RICHARD
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 1:1490 E FOREMASTER DR
Mailing Address - Street 2:SUITE 260
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-4488
Mailing Address - Country:US
Mailing Address - Phone:435-688-0156
Mailing Address - Fax:435-688-0330
Practice Address - Street 1:1490 E FOREMASTER DR
Practice Address - Street 2:# 260
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-4488
Practice Address - Country:US
Practice Address - Phone:435-688-0156
Practice Address - Fax:435-688-0330
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2010-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT95-875021205207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTGO2585Medicare UPIN
UT000011531Medicare ID - Type Unspecified