Basic Information
| Provider Information | |||||||||
| NPI: | 1215989199 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | IVAN | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 630 PLANTATION ST | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016052038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088532716 | ||||||||
| FaxNumber: | 5088569025 | ||||||||
| Practice Location | |||||||||
| Address1: | 135 GOLD STAR BLVD | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088532716 | ||||||||
| FaxNumber: | 5088569025 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 02/13/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 36946 | MA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.