Organization
T G GREEN DO SC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
THEODORE G GREEN D.O. (PHYSICIAN)
(262) 781-1530
Entity
Organization
Contact information
Practice address
13760 W CAPITOL DR, BROOKFIELD, WI 53005-2407
(262) 781-1530
(262) 781-7941
Mailing address
13760 W CAPITOL DR, BROOKFIELD, WI 53005-2407
(262) 781-1530
(262) 781-7941
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
16986
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
30039500
—
WI
Enumeration date
12/01/2010
Last updated
12/01/2010
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