Provider Demographics
NPI:1053414581
Name:GREEN, MICHAEL E (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:E
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:854 LONE OAK DRIVE
Mailing Address - Street 2:
Mailing Address - City:GALLATIN
Mailing Address - State:TN
Mailing Address - Zip Code:37066
Mailing Address - Country:US
Mailing Address - Phone:615-452-1602
Mailing Address - Fax:615-451-0139
Practice Address - Street 1:854 LONE OAK DRIVE
Practice Address - Street 2:
Practice Address - City:GALLATIN
Practice Address - State:TN
Practice Address - Zip Code:37066
Practice Address - Country:US
Practice Address - Phone:615-452-1602
Practice Address - Fax:615-451-0139
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000025545207W00000X
ARC7923207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
0191345OtherTENNCARE SELECT
0840119OtherUNITED HEALTHCARE
877710OtherCLARITY VISION
NASH86608OtherPHCS
TN5545OtherEYEMED
TN3083540Medicaid
4480107OtherAETNA
2680132003OtherCIGNA COMMERCIAL
282865OtherONE HEALTH
TN0191345OtherBLUE CROSS BLUE SHIELD
TN3373178Medicaid
621571208003OtherCIGNA
905714OtherBLOCK VISION
2680132004OtherCIGNA FLEX
0191345OtherTENNCARE SELECT
2680132003OtherCIGNA COMMERCIAL
TN3083540Medicare ID - Type UnspecifiedINDIVIDUAL
TN180019007Medicare PIN