Healthcare Provider Details

I. General information

NPI: 1073704151
Provider Name (Legal Business Name): GAIL SUE-ANN ROSE-GREEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2007
Last Update Date: 08/24/2021
Certification Date: 08/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PM PEDIATRICS OF ANNAPOLIS FESTIVAL AT RIVA SHOPPING CENTER, 2301-A FOREST DRIVE
ANNAPOLIS MD
21401
US

IV. Provider business mailing address

8585 DARK HAWK CIR
COLUMBIA MD
21045-5614
US

V. Phone/Fax

Practice location:
  • Phone: 410-266-6767
  • Fax: 410-266-6761
Mailing address:
  • Phone: 276-886-0545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number268459
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0084290
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: