Healthcare Provider Details

I. General information

NPI: 1366466278
Provider Name (Legal Business Name): ADAM S GREEN MSPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 12/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

467 BOULEVARD
KENILWORTH NJ
07033-1664
US

IV. Provider business mailing address

467 BOULEVARD
KENILWORTH NJ
07033-1664
US

V. Phone/Fax

Practice location:
  • Phone: 908-377-4095
  • Fax:
Mailing address:
  • Phone: 908-377-4095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA00915900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: