Provider Demographics
NPI:1770511404
Name:GREEN, RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
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 1:676 N SAINT CLAIR ST STE 1440
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2927
Mailing Address - Country:US
Mailing Address - Phone:312-695-5620
Mailing Address - Fax:312-695-7095
Practice Address - Street 1:259 E ERIE ST FL 16
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2987
Practice Address - Country:US
Practice Address - Phone:312-695-5620
Practice Address - Fax:312-695-0042
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036075792207RI0008X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207RI0008XAllopathic & Osteopathic PhysiciansInternal MedicineHepatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E18544Medicare UPIN