Healthcare Provider Details

I. General information

NPI: 1134503774
Provider Name (Legal Business Name): MR. MATTHEW COREY GREEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2015
Last Update Date: 07/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 CAHABA VALLEY PKWY SUITE 100
PELHAM AL
35124-1185
US

IV. Provider business mailing address

120 CAHABA VALLEY PKWY SUITE 100
PELHAM AL
35124-1185
US

V. Phone/Fax

Practice location:
  • Phone: 205-621-3778
  • Fax: 205-621-4835
Mailing address:
  • Phone: 205-621-3778
  • Fax: 205-621-4835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number1-139417
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: