Provider Demographics
NPI:1104006105
Name:HENRY L GREEN MD PC
Entity Type:Organization
Organization Name:HENRY L GREEN MD PC
Other - Org Name:SOUTHFIELD CARDIOVASCULAR ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-569-0122
Mailing Address - Street 1:22255 GREENFIELD
Mailing Address - Street 2:SUITE 231
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-3728
Mailing Address - Country:US
Mailing Address - Phone:248-569-0122
Mailing Address - Fax:248-569-3758
Practice Address - Street 1:22255 GREENFIELD
Practice Address - Street 2:SUITE 231
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3728
Practice Address - Country:US
Practice Address - Phone:248-569-0122
Practice Address - Fax:248-569-3758
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HENRY L GREEN MD PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-07
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI21840207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N80170Medicare PIN
MIA78297Medicare UPIN