Provider Demographics
NPI:1033104294
Name:GREEN, KELLI (MD)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 HICKMAN RD
Mailing Address - Street 2:BROADLAWNS MEDICAL CENTER
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50314-1505
Mailing Address - Country:US
Mailing Address - Phone:515-282-2319
Mailing Address - Fax:515-282-3234
Practice Address - Street 1:1801 HICKMAN RD
Practice Address - Street 2:BROADLAWNS MEDICAL CENTER
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314-1505
Practice Address - Country:US
Practice Address - Phone:515-282-2319
Practice Address - Fax:515-282-3234
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA347962084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA286476Medicaid
IAD98420Medicare UPIN
IAI9966Medicare ID - Type Unspecified