Basic Information
| Provider Information | |||||||||
| NPI: | 1073719803 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 23073 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392253073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012006162 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 969 LAKELAND DR | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012006162 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2007 | ||||||||
| LastUpdateDate: | 10/06/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 135313 | NC | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 17833 | MS | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 512I360002 | 01 | MS | PTAN | OTHER | 179024 | 05 | AL | MEDICAID | P01195515 | 01 | MS | RAILROAD MEDICARE PTAN | OTHER |