Provider Demographics
NPI:1447355540
Name:GREEN, RICHARD (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2203 W 116TH PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-4735
Mailing Address - Country:US
Mailing Address - Phone:773-445-3933
Mailing Address - Fax:773-445-3935
Practice Address - Street 1:2203 W 116TH PL
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-4735
Practice Address - Country:US
Practice Address - Phone:773-445-3933
Practice Address - Fax:773-445-3935
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360422992085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1618334OtherBCBS ID
IL036042299Medicaid
ILP00048214OtherRAILROAD
IL036042299Medicaid
ILK45408Medicare PIN
D69816Medicare UPIN