Provider Demographics
NPI:1083724397
Name:GREEN, ALBERT MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:ALBERT
Middle Name:MICHAEL
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 1:1001 LAKESIDE AVE E
Mailing Address - Street 2:#1200
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44114-1158
Mailing Address - Country:US
Mailing Address - Phone:216-479-5541
Mailing Address - Fax:216-479-5554
Practice Address - Street 1:2665 HADDAM RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44120-1531
Practice Address - Country:US
Practice Address - Phone:216-531-5317
Practice Address - Fax:216-371-8833
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-050675207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0935411Medicaid
OHGR0872061Medicaid
GR0872061Medicare ID - Type Unspecified
OHH012160Medicare PIN
OH0935411Medicaid