Basic Information
| Provider Information | |||||||||
| NPI: | 1790909489 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3841 GREEN HILLS VILLAGE DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372152691 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6159362000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3601 THE VANDERBILT CLINIC | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372323937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6159369177 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2007 | ||||||||
| LastUpdateDate: | 03/31/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 45891 | TN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | 45891 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | P01391750 | 01 | TN | RRMC | OTHER | 1521978 | 05 | TN | MEDICAID |