Individual
CHARLES R GREEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
612 N ANDOVER RD, ANDOVER, KS 67002-9778
(316) 733-6618
(316) 733-5299
Mailing address
PO BOX 8035, WICHITA, KS 67208-0035
(316) 689-9135
(316) 689-9102
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
30255
KS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100641000A
—
KS
01
—
103199
MEDICARE
—
Enumeration date
06/27/2006
Last updated
03/31/2016
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