Provider Demographics
NPI:1720373335
Name:GREEN, TORRANCE TREMAYNE (MD)
Entity Type:Individual
Prefix:
First Name:TORRANCE
Middle Name:TREMAYNE
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 1:4617 BILLY FIELDS RD
Mailing Address - Street 2:
Mailing Address - City:EDWARDS
Mailing Address - State:MS
Mailing Address - Zip Code:39066-9151
Mailing Address - Country:US
Mailing Address - Phone:601-832-8922
Mailing Address - Fax:
Practice Address - Street 1:2506 LAKELAND DR STE 310
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-7640
Practice Address - Country:US
Practice Address - Phone:601-832-8922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-10
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS23305207RN0300X, 207R00000X
LAMD.206275207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAINTERNMedicaid