Provider Demographics
NPI:1013947829
Name:GREEN, LINDA MARIE (DO)
Entity Type:Individual
Prefix:DR
First Name:LINDA
Middle Name:MARIE
Last Name:GREEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:19910 CANTERBURY RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-1811
Mailing Address - Country:US
Mailing Address - Phone:313-863-0053
Mailing Address - Fax:313-833-7851
Practice Address - Street 1:4727 SAINT ANTOINE ST
Practice Address - Street 2:SUITE 211
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-1461
Practice Address - Country:US
Practice Address - Phone:313-833-5032
Practice Address - Fax:313-833-7851
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101009317207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI114750368Medicaid
MI0P24770Medicare ID - Type Unspecified
MI114750368Medicaid