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General NPI Number Information
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NPI Number | 1013124296
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Entity Type | Individual
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Provider Name | ALYSIA L GREEN MD
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Gender | Female
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Dates
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Enumeration Date | 05/17/2007
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Last Update Date | 09/12/2024
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Provider Practice Location Address
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Address Line | 633 EMERSON ST
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City | EVANSTON
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State | IL
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Zip | 60208-1394
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Country | US
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Telephone | 847-491-8100
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Fax | 847-491-5919
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Provider Business Mailing Address
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Address Line | 801 ALBANY ST FL G
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City | BOSTON
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State | MA
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Zip | 02119-3791
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Country | US
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Telephone | 617-414-6034
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QS0010X
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Taxonomy Name | Sports Medicine (Family Medicine) Physician
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License Number | 232853
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License Number State | MA
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Taxonomy #2
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Taxonomy Code | 207QS0010X
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Taxonomy Name | Sports Medicine (Family Medicine) Physician
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License Number | 036171538
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License Number State | IL
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