Provider Demographics
NPI:1619279346
Name:T G GREEN DO SC
Entity Type:Organization
Organization Name:T G GREEN DO SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:G
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:262-781-1530
Mailing Address - Street 1:13760 W CAPITOL DR
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-2407
Mailing Address - Country:US
Mailing Address - Phone:262-781-1530
Mailing Address - Fax:262-781-7941
Practice Address - Street 1:13760 W CAPITOL DR
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-2407
Practice Address - Country:US
Practice Address - Phone:262-781-1530
Practice Address - Fax:262-781-7941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-01
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16986207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30039500Medicaid
WI30039500Medicaid
WI000080160Medicare PIN