Basic Information
Provider Information | |||||||||
NPI: | 1164629754 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GREEN | ||||||||
FirstName: | HILMA | ||||||||
MiddleName: | LISA | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 9224 | ||||||||
Address2: |   | ||||||||
City: | BELFAST | ||||||||
State: | ME | ||||||||
PostalCode: | 049159224 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8778481457 | ||||||||
FaxNumber: | 6154653017 | ||||||||
Practice Location | |||||||||
Address1: | 4150 NELSON RD | ||||||||
Address2: | BLDG G, SUITE 7 | ||||||||
City: | LAKE CHARLES | ||||||||
State: | LA | ||||||||
PostalCode: | 706054148 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3375623773 | ||||||||
FaxNumber: | 3375623697 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/28/2007 | ||||||||
LastUpdateDate: | 11/10/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD.201720 | LA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208000000X | MD.201720 | LA | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 1018953 | 05 | LA |   | MEDICAID |