MEDICARE: LISA L 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	208000000X	Pediatrics Physician	35058305	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457311078
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA L GREEN MD

Provider Business Mailing Address
First Line	:	5275 WINNESTE AVE
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45232-1130
Country	:	US
Telephone Number	:	513-242-1033
Fax Number	:	513-242-1539

Provider Business Practice Location Address
First Line	:	5275 WINNESTE AVE
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45232-1130
Country	:	US
Telephone Number	:	513-242-1033
Fax Number	:	513-242-1539

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

Provider Enumeration Date	:	03/27/2006
Last Update Date	:	07/08/2007

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Directions to “ LISA L GREEN MD” Practice Location

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