Provider Demographics
NPI:1770561615
Name:GREEN, GARY LEE (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:LEE
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 1:400 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-7662
Mailing Address - Country:US
Mailing Address - Phone:207-289-1025
Mailing Address - Fax:207-289-1028
Practice Address - Street 1:400 ENTERPRISE DR
Practice Address - Street 2:
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-7662
Practice Address - Country:US
Practice Address - Phone:207-289-1025
Practice Address - Fax:207-289-1028
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-01
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME013090207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C47254Medicare UPIN
MM3672Medicare PIN