Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223G0001X | General Practice | 12012283A | IN |
Y | 213EG0000X | General Practice | 12012283A | IN |
NPI | 1003298076 |
---|---|
Provider Name | Dr. Brooks Andrew Green |
First Address | Lyons, IN 47443-9502 |
Second Address | Lyons, IN 47443-9502 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/06/2015 |
Last Update Date | 25/06/2015 |