Provider Demographics
NPI:1114031937
Name:GREEN, JEFFREY J (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:J
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 LINVILLE DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:PARIS
Mailing Address - State:KY
Mailing Address - Zip Code:40361-2128
Mailing Address - Country:US
Mailing Address - Phone:859-987-3577
Mailing Address - Fax:859-987-3593
Practice Address - Street 1:8 LINVILLE DR
Practice Address - Street 2:SUITE A
Practice Address - City:PARIS
Practice Address - State:KY
Practice Address - Zip Code:40361-2128
Practice Address - Country:US
Practice Address - Phone:859-987-3577
Practice Address - Fax:859-987-3593
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY34918207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000727377OtherANTHEM
KY64349186Medicaid
H42752Medicare UPIN
KYK013220Medicare PIN