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General NPI Number Information
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NPI Number | 1336701861
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Entity Type | Individual
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Provider Name | OTTAVIA KIMBERLY GREEN MD
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Gender | Female
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Dates
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Enumeration Date | 07/04/2019
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Last Update Date | 02/05/2025
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Provider Practice Location Address
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Address Line | 1775 DEMPSTER ST
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City | PARK RIDGE
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State | IL
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Zip | 60068-1143
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Country | US
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Telephone | 847-723-2210
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Fax |
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Provider Business Mailing Address
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Address Line | 29373 NETWORK PL
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City | CHICAGO
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State | IL
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Zip | 60673-1293
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Country | US
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Telephone |
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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 | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | 2019022382
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | V0407
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License Number State | TX
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Taxonomy #3
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | 036-170213
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License Number State | IL
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