Provider Demographics
NPI:1699122630
Name:GREEN, TEDEAN KARISSA
Entity type:Individual
Prefix:MRS
First Name:TEDEAN
Middle Name:KARISSA
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 RIVERFRONT DR UNIT 17F
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48226-4578
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4201 SAINT ANTOINE ST # UHC
Practice Address - Street 2:DEPARTMENT OF OTOLARYNGOLOGY-HEAD AND NECK SURGERY
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2153
Practice Address - Country:US
Practice Address - Phone:269-924-9783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-19
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program