Healthcare Provider Details

I. General information

NPI: 1124207337
Provider Name (Legal Business Name): HARVEY J. GREEN,M.D.,PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2007
Last Update Date: 10/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 NICOLLET MALL SUITE 1645
MINNEAPOLIS MN
55402-2606
US

IV. Provider business mailing address

825 NICOLLET MALL SUITE 1645
MINNEAPOLIS MN
55402-2606
US

V. Phone/Fax

Practice location:
  • Phone: 612-339-7904
  • Fax:
Mailing address:
  • Phone: 612-339-7904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number27598
License Number StateMN

VIII. Authorized Official

Name: DR. HARVEY JOEL GREEN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 61213397904