NPIMap

Organization Active NPI

Kerry S Green MD PLC

Doing business as Skyline Medicine

  • Clinic/Center
  • Mesa, AZ
National Provider Identifier
1356523492
Registry record updated Mar 8, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinic/CenterTaxonomy code 261Q00000X
License
29662 Issued in AZ
Legal business name
KERRY S GREEN MD PLC
Doing business as
Skyline Medicine
Practice address
6112 E Brown Rd
Mesa, AZ 85205-4955
Phone
(480) 924-4422
NPI assigned
Nov 30, 2007
Last updated
Mar 8, 2012By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 8, 2012

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Kerry Green, MDNPI 1801835350
Title
Owner
Phone
(480) 924-4422

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X 29662 AZ Primary

Addresses

Primary practice location

6112 E Brown Rd
Mesa, AZ 85205-4955

Mailing address

6112 E Brown Rd
Mesa, AZ 85205-4955
Phone (480) 924-4422

Other names 1

  • Skyline Medicine Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AZ

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040621001436 AZ Part B Supplier - Clinic/Group Practice 3476538729 Receives reassigned benefits from 10 practitioners
Practice locations: Mesa, AZ

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
03D1056672Skyline Medicine6112 E Brown Rd, Mesa, AZ 85205Certificate of waiverJul 20, 2026

National Provider Directory

National Provider Directory

Locations

6112 E Brown Rd
Mesa, AZ 85205
Phone (480) 924-4422

Practitioners & affiliated clinicians

Practitioners 11

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1196380800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1331164800000",
    "number": "1356523492",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6112 E BROWN RD",
            "city": "MESA",
            "state": "AZ",
            "postal_code": "852054955",
            "telephone_number": "480-924-4422"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6112 E BROWN RD",
            "city": "MESA",
            "state": "AZ",
            "postal_code": "852054955",
            "telephone_number": "480-924-4422"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KERRY S GREEN MD PLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-11-30",
        "last_updated": "2012-03-08",
        "status": "A",
        "authorized_official_last_name": "GREEN",
        "authorized_official_first_name": "KERRY",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "480-924-4422",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": "AZ",
            "license": "29662",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Skyline Medicine",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Mesa, AZ

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 8, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.