Provider Demographics
NPI:1235199183
Name:GREEN, EDWIN JAY (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:JAY
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1317 N ELM ST
Mailing Address - Street 2:STE 2
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-1033
Mailing Address - Country:US
Mailing Address - Phone:336-373-1676
Mailing Address - Fax:
Practice Address - Street 1:1317 N ELM ST
Practice Address - Street 2:STE 2
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1033
Practice Address - Country:US
Practice Address - Phone:336-373-1676
Practice Address - Fax:336-665-6188
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC20140207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8936887Medicaid
C80990Medicare UPIN
NC8936887Medicaid