MEDICARE: MICHAEL D 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	207P00000X	Emergency Medicine Physician	036089809	IL

General Provider Information

NPI Number	:	1164447181
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL D GREEN M.D.

Provider Business Mailing Address
First Line	:	1340 W NEWPORT AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-1412
Country	:	US
Telephone Number	:	773-477-4432
Fax Number	:

Provider Business Practice Location Address
First Line	:	1133 W ARMITAGE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-4103
Country	:	US
Telephone Number	:	773-549-4772
Fax Number	:

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

Provider Enumeration Date	:	07/12/2006
Last Update Date	:	02/18/2015

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