Individual
DR. RANDALL WILLIAM GREEN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
4070 LAKE DR SE, GRAND RAPIDS, MI 49546-8294
(616) 774-8200
(616) 774-0304
Mailing address
4070 LAKE DR SE, GRAND RAPIDS, MI 49546-8294
(616) 774-8200
(616) 774-0304
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
RG030071
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1073594
—
MI
01
—
110158828
RAILROAD MEDICARE
MI
01
—
1104110132
BLUE CROSS BLUE SHIELD
MI
01
—
RG030071
STATE LICENSE NUMBER
MI
Enumeration date
05/04/2006
Last updated
03/07/2023
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