Individual
JIMMY W GREEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
600 GRESHAM DR, NORFOLK, VA 23507-1904
(757) 388-3221
(757) 388-3799
Mailing address
PO BOX 20452, PSMG-CREDENTIALING, COLUMBUS, OH 43220-0452
(614) 442-2406
(614) 442-2410
Taxonomy
Speciality
Code
Description
License number
State
207ZF0201X
Forensic Pathology Physician
026285
GA
207ZP0102X
Anatomic Pathology & Clinical Pathology Physician
Primary
0101-241204
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1174503494
—
VA
01
—
P00396483
RR MEDICARE
VA
Enumeration date
01/20/2006
Last updated
12/22/2014
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