Individual
DIANE ELAINE GREEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
708 W FOREST AVE, JACKSON, TN 38301-3901
(731) 660-8759
Mailing address
1804 HIGHWAY 45 BYP, SUITE 604, JACKSON, TN 38305-4436
(731) 660-8759
Taxonomy
Speciality
Code
Description
License number
State
207ZP0102X
Anatomic Pathology & Clinical Pathology Physician
Primary
13431
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
220016966
RR MEDICARE
—
01
—
3067959
BCBS
—
05
—
3188084
—
TN
05
—
3188085
—
TN
05
—
3188088
—
TN
Enumeration date
03/02/2006
Last updated
07/17/2009
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