1184646929 NPI number — DR. ERIC BRENT GREEN M.D.

Table of content: DR. ERIC BRENT GREEN M.D. (NPI 1184646929)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184646929 NPI number — DR. ERIC BRENT GREEN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREEN
Provider First Name:
ERIC
Provider Middle Name:
BRENT
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:
1184646929
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
210 25TH AVE N
Provider Second Line Business Mailing Address:
SUITE 602
Provider Business Mailing Address City Name:
NASHVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37203-1606
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-312-0612
Provider Business Mailing Address Fax Number:
615-312-0612

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
210 25TH AVE N
Provider Second Line Business Practice Location Address:
SUITE 602
Provider Business Practice Location Address City Name:
NASHVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37203-1606
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-327-4737
Provider Business Practice Location Address Fax Number:
615-327-4737
Provider Enumeration Date:
07/24/2006

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: 2085R0202X , with the licence number:  0101239681 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3834389 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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