Provider Demographics
NPI:1285839688
Name:GREEN MEDICAL GROUP, PC
Entity type:Organization
Organization Name:GREEN MEDICAL GROUP, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANET
Authorized Official - Middle Name:H
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-437-1913
Mailing Address - Street 1:PO BOX 868
Mailing Address - Street 2:
Mailing Address - City:STEVENSON
Mailing Address - State:AL
Mailing Address - Zip Code:35772-0868
Mailing Address - Country:US
Mailing Address - Phone:256-437-1913
Mailing Address - Fax:256-437-1918
Practice Address - Street 1:42950 AL HWY 72
Practice Address - Street 2:SUITE 301
Practice Address - City:STEVENSON
Practice Address - State:AL
Practice Address - Zip Code:35772
Practice Address - Country:US
Practice Address - Phone:256-437-1913
Practice Address - Fax:256-437-1918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL26020207Q00000X
AL26043207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL=========OtherTAX ID NUMBER
K023Medicare ID - Type UnspecifiedPROVIDER #