Healthcare Provider Details

I. General information

NPI: 1790748283
Provider Name (Legal Business Name): HUNTER GREEN PLOG RD, LDN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 01/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1019 MONROE AVE
SAINT MICHAELS MD
21663-2960
US

IV. Provider business mailing address

1019 MONROE AVE
SAINT MICHAELS MD
21663-2960
US

V. Phone/Fax

Practice location:
  • Phone: 443-786-2051
  • Fax:
Mailing address:
  • Phone: 443-786-2051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberD02221
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: