MEDICARE: SHAUNEA IMANI GREEN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program	06-0646844	CT
2	207P00000X	Emergency Medicine Physician	80675	CT

General Provider Information

NPI Number	:	1427851195
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAUNEA IMANI GREEN MD

Provider Business Mailing Address
First Line	:	263 FARMINGTON AVE
Second Line	:
City	:	FARMINGTON
State	:	CT
Zip	:	06030-0002
Country	:	US
Telephone Number	:	860-679-1620
Fax Number	:

Provider Business Practice Location Address
First Line	:	263 FARMINGTON AVE
Second Line	:
City	:	FARMINGTON
State	:	CT
Zip	:	06030-0002
Country	:	US
Telephone Number	:	860-679-1620
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/28/2025
Last Update Date	:	04/06/2026

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