Provider Demographics
NPI:1215911904
Name:GREEN, JEFFERY (MD)
Entity type:Individual
Prefix:
First Name:JEFFERY
Middle Name:
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 1:800 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:MN
Mailing Address - Zip Code:56031-4575
Mailing Address - Country:US
Mailing Address - Phone:507-238-8555
Mailing Address - Fax:
Practice Address - Street 1:800 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:MN
Practice Address - Zip Code:56031-4575
Practice Address - Country:US
Practice Address - Phone:507-238-8555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN42651207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN01-13052OtherMEDICA
FM150697Medicaid
MN007R5GROtherBCBS
MN3153445Medicaid
MN398640300Medicaid
MNA037OtherCHAMPUS
MNMH9041024627OtherPPO
MN1053638OtherARAZ
MN007R5GROtherBCBS/MEDICARE SUPPLEMENT
MN007R5GRMedicaid
MN20227OtherSIOUX VALLEY
MNHP30910OtherHEALTH PARTNERS
MN80013639Medicare ID - Type UnspecifiedMEDICARE
MN007R5GRMedicaid
MNHP30910OtherHEALTH PARTNERS