Provider Demographics
NPI:1306018791
Name:GREEN CLINIC P.C.
Entity Type:Organization
Organization Name:GREEN CLINIC P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-755-2255
Mailing Address - Street 1:5220 PARK AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-3548
Mailing Address - Country:US
Mailing Address - Phone:901-755-2255
Mailing Address - Fax:901-755-9566
Practice Address - Street 1:5220 PARK AVE STE 150
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-3548
Practice Address - Country:US
Practice Address - Phone:901-755-2255
Practice Address - Fax:901-755-9566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-26
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD25222207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3720127Medicaid
TNF76591Medicare UPIN
TN3720127Medicare PIN