Healthcare Provider Details

I. General information

NPI: 1497773824
Provider Name (Legal Business Name): CARMEN R GREEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 10/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 EAST EISENHOWER PARKWAY SUITE 100
ANN ARBOR MI
48108-5721
US

IV. Provider business mailing address

3621 S STATE ST 700 KMS PLACE
ANN ARBOR MI
48108
US

V. Phone/Fax

Practice location:
  • Phone: 734-763-5459
  • Fax:
Mailing address:
  • Phone: 734-936-2047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number4301052368
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number4301052368
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: