Healthcare Provider Details

I. General information

NPI: 1104006105
Provider Name (Legal Business Name): HENRY L GREEN MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2007
Last Update Date: 07/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22255 GREENFIELD SUITE 231
SOUTHFIELD MI
48075-3728
US

IV. Provider business mailing address

22255 GREENFIELD SUITE 231
SOUTHFIELD MI
48075-3728
US

V. Phone/Fax

Practice location:
  • Phone: 248-569-0122
  • Fax: 248-569-3758
Mailing address:
  • Phone: 248-569-0122
  • Fax: 248-569-3758

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number21840
License Number StateMI

VIII. Authorized Official

Name: DR. HENRY L GREEN
Title or Position: MD/PRESIDENT
Credential: MD
Phone: 248-569-0122