MEDICARE: DR. RICHARD GREEN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	036042299	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1618334	OTHER	IL	BCBS ID
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	P00048214	OTHER	IL	RAILROAD

General Provider Information

NPI Number	:	1447355540
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD GREEN M.D.

Provider Business Mailing Address
First Line	:	2203 W 116TH PL
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60643-4735
Country	:	US
Telephone Number	:	773-445-3933
Fax Number	:	773-445-3935

Provider Business Practice Location Address
First Line	:	2203 W 116TH PL
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60643-4735
Country	:	US
Telephone Number	:	773-445-3933
Fax Number	:	773-445-3935

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/13/2006
Last Update Date	:	11/20/2014

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