MEDICARE: MRS. VICTORIA LA SHELLE 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	207V00000X	Obstetrics & Gynecology Physician	038240	GA

General Provider Information

NPI Number	:	1477650273
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. VICTORIA LA SHELLE GREEN MD

Provider Business Mailing Address
First Line	:	69 JESSE HILL JR DR SE
Second Line	:	4TH FLOOR DEPT GYN/OB
City	:	ATLANTA
State	:	GA
Zip	:	30303-3033
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	69 JESSE HILL JR DR SE
Second Line	:	4TH FLOOR DEPT GYN/OB
City	:	ATLANTA
State	:	GA
Zip	:	30303-3033
Country	:	US
Telephone Number	:	404-616-3540
Fax Number	:

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

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	07/08/2007

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