Basic Information
Provider Information | |||||||||
NPI: | 1366875908 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GREEN | ||||||||
FirstName: | TERRA | ||||||||
MiddleName: | E. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | N.P. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1905 E HUEBBE PKWY | ||||||||
Address2: | BELOIT HEALTH SYSTEM | ||||||||
City: | BELOIT | ||||||||
State: | WI | ||||||||
PostalCode: | 535111842 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6083642200 | ||||||||
FaxNumber: | 6083637395 | ||||||||
Practice Location | |||||||||
Address1: | 1905 E HUEBBE PKWY | ||||||||
Address2: | BELOIT CLINIC | ||||||||
City: | BELOIT | ||||||||
State: | WI | ||||||||
PostalCode: | 535111842 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6083642240 | ||||||||
FaxNumber: | 6083637374 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/19/2013 | ||||||||
LastUpdateDate: | 04/09/2015 | ||||||||
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 | 208M00000X | 147601-30 | WI | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 363L00000X | 147601-030 | WI | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363L00000X | 5411-33 | WI | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 1366875908 | 05 | WI |   | MEDICAID |