Individual
DR. KENNETH O GREEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D,
Contact information
Practice address
111 W LINCOLN ST, BELLEVILLE, IL 62220-2019
(618) 234-1774
(618) 234-7979
Mailing address
111 W LINCOLN ST, BELLEVILLE, IL 62220-2019
(618) 234-1774
(618) 234-7979
Taxonomy
Speciality
Code
Description
License number
State
207W00000X
Ophthalmology Physician
Primary
036037266
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036037266
—
IL
01
—
1376586685
NPI GROUP
IL
01
—
211586
MEDICARE GROUP
IL
01
—
CH6508
MEDICARE RAILROAD GROUP
IL
01
—
P00216102
MEDICARE RAILROAD
IL
Enumeration date
06/22/2005
Last updated
04/13/2009
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