Active NPI
Kenneth O Green, M.D,
- Ophthalmology Physician
- Belleville, IL
National Provider Identifier
1780680900
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Ophthalmology Physician
- License
- 036037266
- Practice address
- 111 W Lincoln St
Belleville, IL 62220-2019 - Phone
- (618) 234-1774
- Fax
- (618) 234-7979
- NPI assigned
- Jun 22, 2005
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Ophthalmology Physician | 207W00000X | 036037266 | IL | Primary |
Addresses
Primary practice location
111 W Lincoln St
Belleville, IL 62220-2019
Mailing address
111 W Lincoln St
Belleville, IL 62220-2019
Phone (618) 234-1774
Other identifiers 5
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1376586685 | Other | IL | NPI GROUP |
| 036037266 | Medicaid | IL | |
| 211586 | Other | IL | MEDICARE GROUP |
| CH6508 | Other | IL | MEDICARE RAILROAD GROUP |
| P00216102 | Other | IL | MEDICARE RAILROAD |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 036037266 | IL | MD | Ophthalmology Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| JFJ Eyecare, LTD | Past | Accepting new patients | |
| SSM Health Care St. Louis | Past | Accepting new patients |
Organizations & group practices 2
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
dba SSM Health St. Mary's Hospital Physician Billing
- Emergency Medicine Physician
- Saint Louis, MO
- NPI 1366400855
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1119398400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1239580800000",
"number": "1780680900",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "111 W LINCOLN ST",
"city": "BELLEVILLE",
"state": "IL",
"postal_code": "622202019",
"telephone_number": "618-234-1774",
"fax_number": "618-234-7979"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "111 W LINCOLN ST",
"city": "BELLEVILLE",
"state": "IL",
"postal_code": "622202019",
"telephone_number": "618-234-1774",
"fax_number": "618-234-7979"
}
],
"practiceLocations": [],
"basic": {
"last_name": "GREEN",
"first_name": "KENNETH",
"middle_name": "O",
"name_prefix": "Dr.",
"credential": "M.D,",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2005-06-22",
"last_updated": "2009-04-13",
"status": "A"
},
"taxonomies": [
{
"code": "207W00000X",
"taxonomy_group": "",
"desc": "Ophthalmology",
"state": "IL",
"license": "036037266",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "NPI GROUP",
"identifier": "1376586685",
"state": "IL"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "036037266",
"state": "IL"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "MEDICARE GROUP",
"identifier": "211586",
"state": "IL"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "MEDICARE RAILROAD GROUP",
"identifier": "CH6508",
"state": "IL"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "MEDICARE RAILROAD",
"identifier": "P00216102",
"state": "IL"
}
],
"endpoints": [],
"other_names": []
}Other providers in Belleville, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 13, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.