Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223G0001X | General Practice | 19A13826 | IL |
Y | 213EG0000X | General Practice | 19A13826 | IL |
NPI | 1003119611 |
---|---|
Provider Name | Michael T Green |
First Address | Schaumburg, IL 60195 |
Second Address | Schaumburg, IL 60195 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 21/12/2010 |
Last Update Date | 21/12/2010 |