Provider Demographics
NPI:1205194156
Name:GREEN, ROSS WAYNE (DPM)
Entity Type:Individual
Prefix:DR
First Name:ROSS
Middle Name:WAYNE
Last Name:GREEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3631 N HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634-2237
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3631 N HARLEM AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-2237
Practice Address - Country:US
Practice Address - Phone:773-725-2953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-29
Last Update Date:2012-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016.005502213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine