Healthcare Provider Details

I. General information

NPI: 1831200476
Provider Name (Legal Business Name): TED ALLEN GREEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 N VIRGINIA AVE
EUREKA MO
63025-1115
US

IV. Provider business mailing address

515 N VIRGINIA AVE
EUREKA MO
63025-1115
US

V. Phone/Fax

Practice location:
  • Phone: 636-587-3000
  • Fax: 636-587-2243
Mailing address:
  • Phone: 636-587-3000
  • Fax: 636-587-2243

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number106508
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: