Provider Demographics
NPI:1174503494
Name:GREEN, JIMMY W (MD)
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:W
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 20452
Mailing Address - Street 2:PSMG-CREDENTIALING
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220-0452
Mailing Address - Country:US
Mailing Address - Phone:614-442-2406
Mailing Address - Fax:614-442-2410
Practice Address - Street 1:600 GRESHAM DR
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1904
Practice Address - Country:US
Practice Address - Phone:757-388-3221
Practice Address - Fax:757-388-3799
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA026285207ZF0201X
VA0101-241204207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZF0201XAllopathic & Osteopathic PhysiciansPathologyForensic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1174503494Medicaid
VAP00396483OtherRR MEDICARE
VA013927P28Medicare PIN