MEDICARE: DR. MICHAEL GREEN M.D.

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	207Q00000X	Family Medicine Physician	31175	MN

General Provider Information

NPI Number	:	1134105778
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL GREEN M.D.

Provider Business Mailing Address
First Line	:	4043 PLEASANT AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55409-1544
Country	:	US
Telephone Number	:	612-823-6921
Fax Number	:

Provider Business Practice Location Address
First Line	:	4100 GRAND AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55409-1539
Country	:	US
Telephone Number	:	612-501-1185
Fax Number	:

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

Provider Enumeration Date	:	12/15/2005
Last Update Date	:	07/08/2007

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