1215911904 NPI number — JEFFERY GREEN M.D.

Table of content: JEFFERY GREEN M.D. (NPI 1215911904)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215911904 NPI number — JEFFERY GREEN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREEN
Provider First Name:
JEFFERY
Provider Middle Name:
Provider Name Prefix Text:
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:
1215911904
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/17/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 MEDICAL CENTER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAIRMONT
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56031-4575
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-238-8555
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 MEDICAL CENTER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRMONT
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56031-4575
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-238-8555
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/06/2005

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: 207Q00000X , with the licence number:  42651 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01-13052 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 150697 , issued by the state of ( FM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 007R5GR . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 3153445 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 398640300 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: A037 . This is a "CHAMPUS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: MH9041024627 . This is a "PPO" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1053638 . This is a "ARAZ" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 007R5GR . This is a "BCBS/MEDICARE SUPPLEMENT" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 007R5GR , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 20227 . This is a "SIOUX VALLEY" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: HP30910 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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