Healthcare Provider Details

I. General information

NPI: 1053392084
Provider Name (Legal Business Name): GRETCHEN ELIZABETH GREEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3186 VILLAGE DR STE 201
FAYETTEVILLE NC
28304-3979
US

IV. Provider business mailing address

3186 VILLAGE DRIVE SUITE 201
FAYETTEVILLE NC
28304
US

V. Phone/Fax

Practice location:
  • Phone: 910-486-5700
  • Fax: 910-486-5950
Mailing address:
  • Phone: 910-486-5700
  • Fax: 910-486-5950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0101244527
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2006-00722
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: