Healthcare Provider Details

I. General information

NPI: 1518556216
Provider Name (Legal Business Name): MICHAEL T GREEN SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2021
Last Update Date: 01/16/2021
Certification Date: 01/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4459 WOODLAND DR APT C
NEW ORLEANS LA
70131-5810
US

IV. Provider business mailing address

4459 WOODLAND DR APT C
NEW ORLEANS LA
70131-5810
US

V. Phone/Fax

Practice location:
  • Phone: 504-930-1540
  • Fax:
Mailing address:
  • Phone: 504-930-1540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number009459087
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: