Basic Information
Provider Information | |||||||||
NPI: | 1770841314 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GREEN | ||||||||
FirstName: | CHRISTINA | ||||||||
MiddleName: | DENISE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MILLER | ||||||||
OtherFirstName: | CHRISTINA | ||||||||
OtherMiddleName: | DENISE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 310 W LOSEY ST | ||||||||
Address2: |   | ||||||||
City: | SCOTT AFB | ||||||||
State: | IL | ||||||||
PostalCode: | 622255250 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6182567669 | ||||||||
FaxNumber: | 6182567619 | ||||||||
Practice Location | |||||||||
Address1: | 310 W LOSEY ST | ||||||||
Address2: |   | ||||||||
City: | SCOTT AFB | ||||||||
State: | IL | ||||||||
PostalCode: | 622255250 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6182567669 | ||||||||
FaxNumber: | 6182567619 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/02/2012 | ||||||||
LastUpdateDate: | 03/17/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207V00000X | E-8669 | AR | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
No ID Information.