Provider Demographics
NPI:1578514469
Name:GREEN, EDWARD RODMAN (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:RODMAN
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 1:106 CENTRAL AVENUE
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-3814
Mailing Address - Country:US
Mailing Address - Phone:256-533-6080
Mailing Address - Fax:256-536-2964
Practice Address - Street 1:106 CENTRAL AVENUE
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-3814
Practice Address - Country:US
Practice Address - Phone:256-533-6080
Practice Address - Fax:256-536-2964
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL82192084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL02445OtherBLUE CROSS BLUE SHIELD
C75797Medicare UPIN