Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RP1001X | Pulmonary Disease | 109780 | MO |
NPI | 1033140553 |
---|---|
Provider Name | Dr. Jonathan M Green |
First Address | Saint Louis, MO 63110-1010 |
Second Address | Saint Louis, MO 63110-1010 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/07/2006 |
Last Update Date | 24/01/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
208248906 | (05) | MO |