Healthcare Provider Details

I. General information

NPI: 1154322790
Provider Name (Legal Business Name): JAMES L GREEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2005
Last Update Date: 08/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 S MICHIGAN AVE 8TH FLOOR EYE CENTER
CHICAGO IL
60616-2333
US

IV. Provider business mailing address

PO BOX 166516
CHICAGO IL
60616-6516
US

V. Phone/Fax

Practice location:
  • Phone: 312-567-2795
  • Fax: 312-567-2783
Mailing address:
  • Phone: 312-567-2795
  • Fax: 312-567-2783

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number03656121
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number03656121
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: