Provider Demographics
NPI:1639175037
Name:GREEN, PHILLIP EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:EDWARD
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:PO BOX 382067
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38183-2067
Mailing Address - Country:US
Mailing Address - Phone:901-761-0800
Mailing Address - Fax:901-761-7738
Practice Address - Street 1:3087 PROFESSIONAL PLZ
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-7912
Practice Address - Country:US
Practice Address - Phone:901-761-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN17865207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00015638Medicaid
TN3026653Medicaid
AR105352001Medicaid