Basic Information
| Provider Information | |||||||||
| NPI: | 1245491679 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | BRIAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4869 DPT 235 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 772104869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8777441141 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3600 FLORIDA BLVD | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708063842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2253877070 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2008 | ||||||||
| LastUpdateDate: | 10/26/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD203561 | LA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | MD203561 | LA | N | Allopathic & Osteopathic Physicians | Hospitalist | 282N00000X | MD203561 | LA | N | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 1091596 | 05 | LA | MEDICAID |