Provider Demographics
NPI:1134122484
Name:GREEN, JAMES R SR (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:R
Last Name:GREEN
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 5378
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-5378
Mailing Address - Country:US
Mailing Address - Phone:601-693-6663
Mailing Address - Fax:601-693-6665
Practice Address - Street 1:2024 15TH ST
Practice Address - Street 2:STE 4N
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-4130
Practice Address - Country:US
Practice Address - Phone:601-693-6663
Practice Address - Fax:601-693-6665
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS05615207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00014061Medicaid
MS00014061Medicaid
MS201816554Medicare PIN