Healthcare Provider Details

I. General information

NPI: 1013124296
Provider Name (Legal Business Name): ALYSIA L GREEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

633 EMERSON ST
EVANSTON IL
60208-1394
US

IV. Provider business mailing address

801 ALBANY ST FL G
BOSTON MA
02119-3791
US

V. Phone/Fax

Practice location:
  • Phone: 847-491-8100
  • Fax: 847-491-5919
Mailing address:
  • Phone: 617-414-6034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number232853
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number036171538
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: