Provider Demographics
NPI:1538843354
Name:GREEN, SUSAN DIANE
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:DIANE
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 E COURT ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-2019
Mailing Address - Country:US
Mailing Address - Phone:217-370-7852
Mailing Address - Fax:
Practice Address - Street 1:307 E COURT ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-2019
Practice Address - Country:US
Practice Address - Phone:217-370-7852
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-12
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty