Healthcare Provider Details

I. General information

NPI: 1528283926
Provider Name (Legal Business Name): CHARLES JOSEPH GREEN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 10/11/2023
Certification Date: 10/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 UNION AVE
SHEBOYGAN WI
53081-8426
US

IV. Provider business mailing address

PO BOX 735044
CHICAGO IL
60673-5044
US

V. Phone/Fax

Practice location:
  • Phone: 920-828-2530
  • Fax: 920-828-2535
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number5101016991
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number55576021
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: