Provider Demographics
NPI:1497773824
Name:GREEN, CARMEN R (MD)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:R
Last Name:GREEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3621 S STATE ST
Mailing Address - Street 2:700 KMS PLACE
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108
Mailing Address - Country:US
Mailing Address - Phone:734-936-2047
Mailing Address - Fax:
Practice Address - Street 1:325 EAST EISENHOWER PARKWAY
Practice Address - Street 2:SUITE 100
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-5721
Practice Address - Country:US
Practice Address - Phone:734-763-5459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301052368207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2905220Medicaid
MI0H16010122Medicare ID - Type Unspecified
MI2905220Medicaid