Provider Demographics
NPI:1780680900
Name:GREEN, KENNETH O (MD,)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:O
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 1:111 W LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-2019
Mailing Address - Country:US
Mailing Address - Phone:618-234-1774
Mailing Address - Fax:618-234-7979
Practice Address - Street 1:111 W LINCOLN ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-2019
Practice Address - Country:US
Practice Address - Phone:618-234-1774
Practice Address - Fax:618-234-7979
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036037266207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1376586685OtherNPI GROUP
IL036037266Medicaid
IL211586OtherMEDICARE GROUP
ILCH6508OtherMEDICARE RAILROAD GROUP
ILP00216102OtherMEDICARE RAILROAD
IL036037266Medicaid
IL554490Medicare PIN
IL211586OtherMEDICARE GROUP