Healthcare Provider Details

I. General information

NPI: 1902890965
Provider Name (Legal Business Name): KERYL JEAN GREEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 MDG UNIT 3215
APO AE
09094
DE

IV. Provider business mailing address

PSC 2 BOX 12602
APO AE
09012
DE

V. Phone/Fax

Practice location:
  • Phone: 01149637146
  • Fax:
Mailing address:
  • Phone: 01149637146
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number36100844
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: