Healthcare Provider Details

I. General information

NPI: 1033143714
Provider Name (Legal Business Name): BRIAN A GREEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 11/21/2024
Certification Date: 11/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1661 INTERNATIONAL PLACE DRIVE SUITE 350
MEMPHIS TN
38120
US

IV. Provider business mailing address

1661 INTERNATIONAL PLACE DRIVE SUITE 350
MEMPHIS TN
38120
US

V. Phone/Fax

Practice location:
  • Phone: 901-685-2696
  • Fax: 901-682-9747
Mailing address:
  • Phone: 901-685-2696
  • Fax: 901-682-9747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number49303
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2004005488
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License NumberMD0000046433
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: