=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013180736
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEANNE GREEN M.D., LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2008
-----------------------------------------------------
Last Update Date | 04/08/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 109 HUNTER STATION WAY
-----------------------------------------------------
City | SELLERSBURG
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47172-8915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-248-4655
-----------------------------------------------------
Fax | 812-248-4656
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 109 HUNTER STATION WAY
-----------------------------------------------------
City | SELLERSBURG
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47172-8915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-248-4655
-----------------------------------------------------
Fax | 812-248-4656
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JEANNE GREEN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 812-248-4655
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 01061001A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------