1053585604 NPI number — DR. JARED ROSS GREEN M.D.

Table of content: DR. JARED ROSS GREEN M.D. (NPI 1053585604)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053585604 NPI number — DR. JARED ROSS GREEN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREEN
Provider First Name:
JARED
Provider Middle Name:
ROSS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053585604
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/07/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 N HIATUS RD STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEMBROKE PINES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33026-5213
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-437-4800
Provider Business Mailing Address Fax Number:
954-437-6628

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1005 JOE DIMAGGIO DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOLLYWOOD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33021-5402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-265-5892
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/15/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085P0229X , with the licence number:  036.130117 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: 036.130117 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 109833300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".