Provider Demographics
NPI:1447468459
Name:GREEN, AMY JENNIFER (MD)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:JENNIFER
Last Name:GREEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:162 OLD POST RD
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:KY
Mailing Address - Zip Code:40361-2713
Mailing Address - Country:US
Mailing Address - Phone:859-987-0632
Mailing Address - Fax:
Practice Address - Street 1:1055 DOVE RUN RD
Practice Address - Street 2:SUITE 200
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40502-3536
Practice Address - Country:US
Practice Address - Phone:859-268-0061
Practice Address - Fax:859-266-1152
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY34917207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64349178Medicaid
KY64349178Medicaid
KY0905242Medicare PIN
KY0692948Medicare PIN
KYHO1974Medicare UPIN