Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208800000X | Urologist | 016803 | GA |
NPI | 1053385716 |
---|---|
Provider Name | Bruce G Green |
First Address | Atlanta, GA 30342-1731 |
Second Address | Atlanta, GA 30342-1731 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/02/2006 |
Last Update Date | 31/08/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
D40009 | (02) |