Provider Demographics
NPI:1033143714
Name:GREEN, BRIAN A (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:A
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1661 INTERNATIONAL PLACE DRIVE
Mailing Address - Street 2:SUITE 350
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120
Mailing Address - Country:US
Mailing Address - Phone:901-685-2696
Mailing Address - Fax:901-682-9747
Practice Address - Street 1:1661 INTERNATIONAL PLACE DRIVE
Practice Address - Street 2:SUITE 350
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120
Practice Address - Country:US
Practice Address - Phone:901-685-2696
Practice Address - Fax:901-682-9747
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD00000464332085P0229X
MO20040054882085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO127217OtherBLUE CHOICE
MO751786OtherHEALTHLINK
MO201269206Medicaid
MO957725236Medicare PIN
MOI56235Medicare UPIN
MOP00322788Medicare PIN
MO127217OtherBLUE CHOICE
MO751786OtherHEALTHLINK