Provider Demographics
NPI:1275611667
Name:GREEN, ALAN F (MD)
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:F
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 252643
Mailing Address - Street 2:
Mailing Address - City:W BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48325-2643
Mailing Address - Country:US
Mailing Address - Phone:313-478-0073
Mailing Address - Fax:
Practice Address - Street 1:2950 E JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-4208
Practice Address - Country:US
Practice Address - Phone:313-567-3551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAG046145207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2799655Medicaid
MI2799655Medicaid
MI0828642Medicare ID - Type Unspecified