Provider Demographics
NPI:1457441016
Name:GREEN, JERRIL (MD)
Entity Type:Individual
Prefix:
First Name:JERRIL
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 1:14319 SAINT MICHAEL DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-5572
Mailing Address - Country:US
Mailing Address - Phone:501-590-2885
Mailing Address - Fax:
Practice Address - Street 1:14319 SAINT MICHAEL DR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-5572
Practice Address - Country:US
Practice Address - Phone:501-590-2885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-19612080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR135223001Medicaid
AR135223001Medicaid
5K946Medicare PIN