Basic Information
| Provider Information | |||||||||
| NPI: | 1053792374 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | DANIEL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1120 W MICHIGAN ST | ||||||||
| Address2: | GATCH HALL, CL 630 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462025209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003622066 | ||||||||
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| Practice Location | |||||||||
| Address1: | ELM AND CARLTON STREETS | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142630001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168452300 | ||||||||
| FaxNumber: | 7168458057 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2015 | ||||||||
| LastUpdateDate: | 05/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 11018274A | IN | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | 310232 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.