Healthcare Provider Details

I. General information

NPI: 1013103811
Provider Name (Legal Business Name): CHRISTOPHER CANFIELD GREEN M.D., PHD, FAAFS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2007
Last Update Date: 11/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50723 HARBOUR VIEW DR S MED:FOR, INC
NEW BALTIMORE MI
48047-4347
US

IV. Provider business mailing address

50723 HARBOUR VIEW DR S
NEW BALTIMORE MI
48047-4347
US

V. Phone/Fax

Practice location:
  • Phone: 586-876-5680
  • Fax: 586-725-4865
Mailing address:
  • Phone: 586-876-5680
  • Fax: 586-725-4865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301087789
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code209800000X
TaxonomyLegal Medicine (M.D./D.O.) Physician
License Number4301087789
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code209800000X
TaxonomyLegal Medicine (M.D./D.O.) Physician
License Number79-166
License Number StateNM
# 4
Primary TaxonomyN
Taxonomy Code209800000X
TaxonomyLegal Medicine (M.D./D.O.) Physician
License NumberMD12109
License Number StateDC
# 5
Primary TaxonomyN
Taxonomy Code2085D0003X
TaxonomyDiagnostic Neuroimaging (Radiology) Physician
License Number4301087789
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: