Provider Demographics
NPI:1073719803
Name:GREEN, EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
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:PO BOX 23073
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-3073
Mailing Address - Country:US
Mailing Address - Phone:601-200-6162
Mailing Address - Fax:
Practice Address - Street 1:969 LAKELAND DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4606
Practice Address - Country:US
Practice Address - Phone:601-200-6162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-27
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1353132085R0202X
MS178332085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS512I360002OtherPTAN
AL179024Medicaid
MSP01195515OtherRAILROAD MEDICARE PTAN
AL179024Medicaid
MSP01195515OtherRAILROAD MEDICARE PTAN