Healthcare Provider Details

I. General information

NPI: 1063874865
Provider Name (Legal Business Name): STEPHANIE E GREEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2016
Last Update Date: 08/02/2022
Certification Date: 08/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 ORLEANS ST RM 8446
BALTIMORE MD
21287-0010
US

IV. Provider business mailing address

6201 GREENLEIGH AVE
MIDDLE RIVER MD
21220-2004
US

V. Phone/Fax

Practice location:
  • Phone: 410-955-5000
  • Fax: 410-367-2203
Mailing address:
  • Phone: 410-933-4380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD94628
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: