Basic Information
| Provider Information | |||||||||
| NPI: | 1023027794 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IVOR GREEN M.D. A PROFESSIONAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 225 S LAKE AVE | ||||||||
| Address2: | 535 | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911013005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6267956596 | ||||||||
| FaxNumber: | 6267958247 | ||||||||
| Practice Location | |||||||||
| Address1: | 438 W LAS TUNAS DR | ||||||||
| Address2: | |||||||||
| City: | SAN GABRIEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917761216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6262895454 | ||||||||
| FaxNumber: | 6264577172 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 02/25/2008 | ||||||||
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| AuthorizedOfficialLastName: | GREEN | ||||||||
| AuthorizedOfficialFirstName: | IVOR | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8188259423 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00A253490 | 05 | CA | MEDICAID | 00A253490 | 01 | CA | BLUE SHIELD | OTHER |