Basic Information
| Provider Information | |||||||||
| NPI: | 1710514138 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | VICTOR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2160 S 1ST AVE | ||||||||
| Address2: | |||||||||
| City: | MAYWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601533328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7082163282 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2160 S 1ST AVE | ||||||||
| Address2: | |||||||||
| City: | MAYWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601533328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7082169000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2020 | ||||||||
| LastUpdateDate: | 06/02/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 125075785 | IL | N | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | 125075785 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.