Basic Information
Provider Information
NPI: 1750368148
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: GREEN
FirstName: JONATHAN
MiddleName: S
NamePrefix: DR.
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 4420 LAKE BOONE TRL
Address2:  
City: RALEIGH
State: NC
PostalCode: 276077505
CountryCode: US
TelephoneNumber: 9197847093
FaxNumber: 9197847395
Practice Location
Address1: 4420 LAKE BOONE TRL
Address2:  
City: RALEIGH
State: NC
PostalCode: 27607
CountryCode: US
TelephoneNumber: 9197847093
FaxNumber: 9197847395
Other Information
ProviderEnumerationDate: 12/27/2005
LastUpdateDate: 03/24/2021
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 03/24/2021

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
208M00000X200100242NCN Allopathic & Osteopathic PhysiciansHospitalist 
207R00000X200100242NCY Allopathic & Osteopathic PhysiciansInternal Medicine 

ID Information
IDTypeStateIssuerDescription
89128U705NC MEDICAID
B6722583701 DEAOTHER
128U701 BCBSOTHER


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