Healthcare Provider Details

I. General information

NPI: 1710418884
Provider Name (Legal Business Name): BENJAMIN GREENE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2017
Last Update Date: 11/18/2021
Certification Date: 11/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 GREENWICH OFFICE PARK
GREENWICH CT
06831-5151
US

IV. Provider business mailing address

3959 BROADWAY
NEW YORK NY
10032-1559
US

V. Phone/Fax

Practice location:
  • Phone: 203-869-1145
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License Number301291
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License NumberFG8950621
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: