Basic Information
| Provider Information | |||||||||
| NPI: | 1760600639 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | JOEL | ||||||||
| MiddleName: | ALLAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1045 GEZON PKWY SW | ||||||||
| Address2: | |||||||||
| City: | WYOMING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495099542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164565311 | ||||||||
| FaxNumber: | 6164567955 | ||||||||
| Practice Location | |||||||||
| Address1: | 1045 GEZON PKWY SW | ||||||||
| Address2: | |||||||||
| City: | WYOMING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495099542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164565311 | ||||||||
| FaxNumber: | 6164567955 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2007 | ||||||||
| LastUpdateDate: | 01/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 4301088236 | MI | Y | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.