Provider Demographics
NPI:1922046200
Name:GREEN, JEFFREY W (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:W
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 1:7714 POPLAR AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-3941
Mailing Address - Country:US
Mailing Address - Phone:901-683-0055
Mailing Address - Fax:901-685-2969
Practice Address - Street 1:7945 WOLF RIVER BLVD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-1762
Practice Address - Country:US
Practice Address - Phone:901-683-0055
Practice Address - Fax:901-685-2969
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0297572085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00126459Medicaid
MO205887201Medicaid
TNQ014089Medicaid
AR145117001Medicaid
TNT13426AOtherMEDICARE TN
MS1A7288OtherMEDICARE MS