Healthcare Provider Details

I. General information

NPI: 1093334088
Provider Name (Legal Business Name): EMILY SMITH GREEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2020
Last Update Date: 01/06/2026
Certification Date: 01/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 S MARYLAND AVE
CHICAGO IL
60637-1443
US

IV. Provider business mailing address

1747 W ROOSEVELT RD
CHICAGO IL
60608-1264
US

V. Phone/Fax

Practice location:
  • Phone: 773-702-2271
  • Fax: 773-702-6649
Mailing address:
  • Phone: 773-702-2271
  • Fax: 773-702-6649

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number036.165457
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number01098470A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: