Healthcare Provider Details

I. General information

NPI: 1184897043
Provider Name (Legal Business Name): DERRICK LAMONT GREEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2008
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 HARVARD ST SE
MINNEAPOLIS MN
55455-0363
US

IV. Provider business mailing address

909 FULTON ST SE
MINNEAPOLIS MN
55455-4800
US

V. Phone/Fax

Practice location:
  • Phone: 612-273-3000
  • Fax: 612-273-4370
Mailing address:
  • Phone: 612-672-7422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number53899
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: