Healthcare Provider Details

I. General information

NPI: 1346879475
Provider Name (Legal Business Name): JOSHUA JAMES GREEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2020
Last Update Date: 12/13/2023
Certification Date: 12/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 BEAUBIEN ST
DETROIT MI
48201-2119
US

IV. Provider business mailing address

30515 JEANINE ST
LIVONIA MI
48152-3475
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-5870
  • Fax:
Mailing address:
  • Phone: 248-496-2542
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301509666
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: