Healthcare Provider Details

I. General information

NPI: 1124531702
Provider Name (Legal Business Name): VILLAGE GREEN PRIMARY CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2017
Last Update Date: 12/03/2024
Certification Date: 12/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1684 VILLAGE GRN LOWR LEVEL
CROFTON MD
21114-2059
US

IV. Provider business mailing address

1684 VILLAGE GRN LOWR LEVEL
CROFTON MD
21114-2059
US

V. Phone/Fax

Practice location:
  • Phone: 410-721-3822
  • Fax: 410-451-0960
Mailing address:
  • Phone: 410-721-3822
  • Fax: 410-451-0960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD0061041
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: ALLISON N WILLIAMS
Title or Position: OWNER EMPLOYEE
Credential: MD
Phone: 410-721-3822