MEDICARE: TE'JAH GREEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171W00000X	Contractor

General Provider Information

NPI Number	:	1093511719
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TE'JAH GREEN

Provider Business Mailing Address
First Line	:	3604 GRIDLEY RD APT 2
Second Line	:
City	:	SHAKER HEIGHTS
State	:	OH
Zip	:	44122-5088
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3604 GRIDLEY RD APT 2
Second Line	:
City	:	SHAKER HEIGHTS
State	:	OH
Zip	:	44122-5088
Country	:	US
Telephone Number	:	614-639-9375
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/22/2025
Last Update Date	:	04/17/2025

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Directions to “ TE'JAH GREEN ” Practice Location

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