Provider Demographics
NPI:1568479939
Name:GREEN, CHRISTOPHER R (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:R
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 1:670 MASON RIDGE CENTER DR
Mailing Address - Street 2:STE 300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8573
Mailing Address - Country:US
Mailing Address - Phone:618-474-1723
Mailing Address - Fax:618-462-6989
Practice Address - Street 1:2 MEMORIAL DR
Practice Address - Street 2:SUITE 220
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-6723
Practice Address - Country:US
Practice Address - Phone:618-474-1723
Practice Address - Fax:618-462-6989
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-064682207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036064682Medicaid
K03363Medicare ID - Type Unspecified
C41836Medicare UPIN