Individual
EDWARD GREEN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
969 LAKELAND DR, JACKSON, MS 39216-4606
(601) 200-6162
Mailing address
PO BOX 23073, JACKSON, MS 39225-3073
(601) 200-6162
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
135313
NC
2085R0202X
Diagnostic Radiology Physician
Primary
17833
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
179024
—
AL
01
—
512I360002
PTAN
MS
01
—
P01195515
RAILROAD MEDICARE PTAN
MS
Enumeration date
06/27/2007
Last updated
10/06/2022
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