Healthcare Provider Details

I. General information

NPI: 1093729014
Provider Name (Legal Business Name): ROOSEVELT GREEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 10/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 PLEASANT ROW NW
HUNTSVILLE AL
35816-2537
US

IV. Provider business mailing address

PO BOX 18488
HUNTSVILLE AL
35804-8488
US

V. Phone/Fax

Practice location:
  • Phone: 256-533-6311
  • Fax:
Mailing address:
  • Phone: 256-534-8659
  • Fax: 256-534-0276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number08804
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: