Provider Demographics
NPI:1710992268
Name:LAURI GREEN M.D. S.C.
Entity Type:Organization
Organization Name:LAURI GREEN M.D. S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAURI
Authorized Official - Middle Name:THERESA
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-695-1212
Mailing Address - Street 1:1177 QUAIL CT
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-3790
Mailing Address - Country:US
Mailing Address - Phone:262-695-1212
Mailing Address - Fax:262-695-1919
Practice Address - Street 1:1177 QUAIL CT
Practice Address - Street 2:SUITE 101
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-3790
Practice Address - Country:US
Practice Address - Phone:262-695-1212
Practice Address - Fax:262-695-1919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI381852084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32265500Medicaid