Provider Demographics
NPI:1609968544
Name:GREEN, MARK ALLEN (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALLEN
Last Name:GREEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:7716 BARBOUR PLACE DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-2730
Mailing Address - Country:US
Mailing Address - Phone:502-561-0490
Mailing Address - Fax:502-409-4964
Practice Address - Street 1:2137 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40210-2242
Practice Address - Country:US
Practice Address - Phone:502-561-0490
Practice Address - Fax:502-409-4964
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3776111N00000X
IN08001343111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000051525OtherANTHEM #
KY50008078OtherPASSPORT PROVIDER #
KY85001758Medicaid
KY2623859000OtherPASSPORT ADVANTAGE ID#
KY2623859000OtherPASSPORT ADVANTAGE ID#
KYT54443Medicare UPIN