Basic Information
| Provider Information | |||||||||
| NPI: | 1568479939 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 670 MASON RIDGE CENTER DR | ||||||||
| Address2: | STE 300 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631418573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184741723 | ||||||||
| FaxNumber: | 6184626989 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 MEMORIAL DR | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620026723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184741723 | ||||||||
| FaxNumber: | 6184626989 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 06/10/2016 | ||||||||
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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 | 207R00000X | 036-064682 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036064682 | 05 | IL | MEDICAID |