Healthcare Provider Details

I. General information

NPI: 1144318775
Provider Name (Legal Business Name): FREDERICK CHAPMAN GREEN JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8802 N 61ST AVE
GLENDALE AZ
85302-4521
US

IV. Provider business mailing address

2101 E REDFIELD RD
PHOENIX AZ
85022-4660
US

V. Phone/Fax

Practice location:
  • Phone: 623-934-1991
  • Fax: 480-733-3031
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number19095
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: