Provider Demographics
NPI:1376578005
Name:GREEN, YIHOODAH Y (MD)
Entity Type:Individual
Prefix:
First Name:YIHOODAH
Middle Name:Y
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 1:1022 N KEDZIE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60651-4128
Mailing Address - Country:US
Mailing Address - Phone:773-486-5031
Mailing Address - Fax:773-522-2449
Practice Address - Street 1:3955 W ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60624-4235
Practice Address - Country:US
Practice Address - Phone:773-522-5540
Practice Address - Fax:773-522-2449
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH79930Medicare UPIN
IL209698Medicare ID - Type Unspecified