Provider Demographics
NPI:1619904539
Name:GREEN, TAMARA G (PT)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:G
Last Name:GREEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:TAMARA
Other - Middle Name:G
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7300 SECOR RD
Practice Address - Street 2:
Practice Address - City:LAMBERTVILLE
Practice Address - State:MI
Practice Address - Zip Code:48144-9376
Practice Address - Country:US
Practice Address - Phone:734-854-1260
Practice Address - Fax:734-854-3581
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT010778225100000X
MI5501016333225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000168967OtherANTHEM
MIN69750098Medicare PIN
366727Medicare ID - Type Unspecified
MIP01343781Medicare PIN