Provider Demographics
NPI:1538150958
Name:GREEN, JEFFREY A (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:A
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 1:6600 N ATWAHL DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-3406
Mailing Address - Country:US
Mailing Address - Phone:414-352-9256
Mailing Address - Fax:
Practice Address - Street 1:5000 W CHAMBERS ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-1650
Practice Address - Country:US
Practice Address - Phone:414-447-2171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI30566207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31564700Medicaid
WI080169564OtherRAILROAD MEDICARE
WI12810OtherDEAN
WI1538150958Medicaid
WI300566OtherTOUCHPOINT
WI1538150958OtherBCBSWI
WIGREENJEFOtherMERCYCARE INSURANCE
WI1538150958Medicaid
WI002801743Medicare PIN
IL$$$$$$$$$ 1Medicaid
WI1538150958OtherBCBSWI
WI12810OtherDEAN
WI31564700Medicaid