Provider Demographics
NPI:1235142308
Name:GREEN, EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
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 660
Mailing Address - Street 2:400 EAST FIRST STREET
Mailing Address - City:MORRIS
Mailing Address - State:MN
Mailing Address - Zip Code:56267-0660
Mailing Address - Country:US
Mailing Address - Phone:320-589-1313
Mailing Address - Fax:320-589-3533
Practice Address - Street 1:400 EAST FIRST STREET
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:MN
Practice Address - Zip Code:56267-0660
Practice Address - Country:US
Practice Address - Phone:320-589-1313
Practice Address - Fax:320-589-3533
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN35398207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology