Johnny Bert Green, MD

Primary specialty

Colon & Rectal Surgery PhysicianTaxonomy code 208C00000X

License

M-11186 Issued in ID

Practice address

1072 N Liberty Street
Suite 201
Boise, ID 83704

Phone

(208) 302-2400

Fax

(208) 302-2455

NPI assigned

Mar 14, 2006

Last updated

Nov 15, 2016By the provider in NPPES

Sex

Male

Sole proprietor

No

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

Specialties & licenses 3

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Saint Alphonsus Regional Medical Center Inc

  • Family Medicine Physician
  • Caldwell, ID
  • NPI 1861676298
  NPD (past)

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

{
    "created_epoch": "1142294400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1479168000000",
    "number": "1386612414",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3340 E GOLDSTONE WAY",
            "city": "MERIDIAN",
            "state": "ID",
            "postal_code": "836421026",
            "telephone_number": "208-302-2400",
            "fax_number": "208-302-2455"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1072 N LIBERTY STREET",
            "address_2": "SUITE 201",
            "city": "BOISE",
            "state": "ID",
            "postal_code": "83704",
            "telephone_number": "208-302-2400",
            "fax_number": "208-302-2455"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "GREEN",
        "first_name": "JOHNNY",
        "middle_name": "BERT",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-03-14",
        "last_updated": "2016-11-15",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "208600000X",
            "taxonomy_group": "",
            "desc": "Surgery",
            "state": "WA",
            "license": "35113",
            "primary": false
        },
        {
            "code": "208C00000X",
            "taxonomy_group": "",
            "desc": "Colon & Rectal Surgery",
            "state": "WA",
            "license": "35113",
            "primary": false
        },
        {
            "code": "208C00000X",
            "taxonomy_group": "",
            "desc": "Colon & Rectal Surgery",
            "state": "ID",
            "license": "M-11186",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1386612414",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Brian H Green, LCSW
• David Charles Green, DDS
• Diana M Green, DO
• Elizabeth Anne Green, NP-C
• Erin Louise Green, RDN, LD
• Matthew Parker Green
• Melissa D Green, PHARMD
• Michael Green, D.C.
• Michael Matthew Green, D.O.
• Sharlene F Green, PSY.D.

• Colon & Rectal Surgery Physician in Boise, ID
• Providers in Boise, ID by specialty
• Colon & Rectal Surgery Physician in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 15, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.