Basic Information
Provider Information | |||||||||
NPI: | 1932465739 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GREEN | ||||||||
FirstName: | CHRISTINA | ||||||||
MiddleName: | K | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SMITH | ||||||||
OtherFirstName: | CHRISTINA | ||||||||
OtherMiddleName: | GREEN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 635283 | ||||||||
Address2: |   | ||||||||
City: | CINCINNATI | ||||||||
State: | OH | ||||||||
PostalCode: | 452635283 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8599126500 | ||||||||
FaxNumber: | 8594421501 | ||||||||
Practice Location | |||||||||
Address1: | 2626 ALEXANDRIA PIKE | ||||||||
Address2: |   | ||||||||
City: | HIGHLAND HEIGHTS | ||||||||
State: | KY | ||||||||
PostalCode: | 410761530 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8599126500 | ||||||||
FaxNumber: | 8594421501 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/05/2012 | ||||||||
LastUpdateDate: | 05/12/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/12/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 49388 | KY | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | 7100432370 | 05 | KY |   | MEDICAID | 0200098 | 05 | OH |   | MEDICAID | 300002709 | 05 | IN |   | MEDICAID |