MEDICARE: TANISHA GREEN MD

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	207L00000X	Anesthesiology Physician	M1117	TX
2	208D00000X	General Practice Physician	M1117	TX

General Provider Information

NPI Number	:	1174616478
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TANISHA GREEN MD

Provider Business Mailing Address
First Line	:	PO BOX 840853
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75284-0863
Country	:	US
Telephone Number	:	713-620-4000
Fax Number	:

Provider Business Practice Location Address
First Line	:	12111 SAN LUCA ST
Second Line	:
City	:	RICHMOND
State	:	TX
Zip	:	77406-1542
Country	:	US
Telephone Number	:	713-882-7223
Fax Number	:

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

Provider Enumeration Date	:	10/02/2006
Last Update Date	:	08/02/2021

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Directions to “ TANISHA GREEN MD” Practice Location

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