Healthcare Provider Details

I. General information

NPI: 1619030012
Provider Name (Legal Business Name): VIRGINIA LITTLE GREEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VIRGINIA ALISON GREEN M.D.

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 W WOODROW WILSON AVE JACKSON MEDICAL MALL, SUITE 454
JACKSON MS
39213-7681
US

IV. Provider business mailing address

PO BOX 1700
JACKSON MS
39215-1700
US

V. Phone/Fax

Practice location:
  • Phone: 601-987-3965
  • Fax: 601-987-4176
Mailing address:
  • Phone: 601-987-3965
  • Fax: 601-987-5560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number10098
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: