Healthcare Provider Details

I. General information

NPI: 1134814577
Provider Name (Legal Business Name): TERRY BERNARD GREEN II
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2023
Last Update Date: 04/11/2023
Certification Date: 04/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 MADISON AVE
TOLEDO OH
43604-1222
US

IV. Provider business mailing address

98 BRUNSON AVE
COLUMBUS OH
43203-1758
US

V. Phone/Fax

Practice location:
  • Phone: 567-312-8700
  • Fax:
Mailing address:
  • Phone: 614-815-9352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: