MEDICARE: DR. KENNETH O 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	207W00000X	Ophthalmology Physician	036037266	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	211586	OTHER	IL	MEDICARE GROUP
4	CH6508	OTHER	IL	MEDICARE RAILROAD GROUP
5	P00216102	OTHER	IL	MEDICARE RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1376586685	OTHER	IL	NPI GROUP
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1780680900
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH O GREEN M.D,

Provider Business Mailing Address
First Line	:	111 W LINCOLN ST
Second Line	:
City	:	BELLEVILLE
State	:	IL
Zip	:	62220-2019
Country	:	US
Telephone Number	:	618-234-1774
Fax Number	:	618-234-7979

Provider Business Practice Location Address
First Line	:	111 W LINCOLN ST
Second Line	:
City	:	BELLEVILLE
State	:	IL
Zip	:	62220-2019
Country	:	US
Telephone Number	:	618-234-1774
Fax Number	:	618-234-7979

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

Provider Enumeration Date	:	06/22/2005
Last Update Date	:	04/13/2009

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Directions to “ DR. KENNETH O GREEN M.D,” Practice Location

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