Basic Information
| Provider Information | |||||||||
| NPI: | 1447468459 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | JENNIFER | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 162 OLD POST RD | ||||||||
| Address2: | |||||||||
| City: | PARIS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403612713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8599870632 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1055 DOVE RUN RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405023536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592680061 | ||||||||
| FaxNumber: | 8592661152 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2007 | ||||||||
| LastUpdateDate: | 05/30/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | KY34917 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64349178 | 05 | KY | MEDICAID |