MEDICARE: DAMON C. 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	207L00000X	Anesthesiology Physician	036109916	IL

General Provider Information

NPI Number	:	1770585267
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAMON C. GREEN M.D.

Provider Business Mailing Address
First Line	:	812 N LOGAN AVE
Second Line	:	ANESTHESIA
City	:	DANVILLE
State	:	IL
Zip	:	61832-3752
Country	:	US
Telephone Number	:	217-477-2940
Fax Number	:	217-477-2936

Provider Business Practice Location Address
First Line	:	812 N LOGAN AVE
Second Line	:	ANESTHESIA
City	:	DANVILLE
State	:	IL
Zip	:	61832-3752
Country	:	US
Telephone Number	:	217-477-2940
Fax Number	:	217-477-2936

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

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

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