Provider Demographics
NPI:1952393027
Name:GREEN, JESSE ANDREW (MD)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:ANDREW
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 1:51 NORTH 39TH STREET
Mailing Address - Street 2:218 WRIGHT SAUNDERS
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104
Mailing Address - Country:US
Mailing Address - Phone:215-662-8900
Mailing Address - Fax:518-262-6470
Practice Address - Street 1:51 NORTH 39TH STREET
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104
Practice Address - Country:US
Practice Address - Phone:215-662-8900
Practice Address - Fax:518-262-6470
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD450077207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01460562Medicaid
NY01460562Medicaid
NY50488GMedicare ID - Type Unspecified