Healthcare Provider Details

I. General information

NPI: 1932397742
Provider Name (Legal Business Name): GLENN JOEL GREENE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2007
Last Update Date: 10/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72 JACOBS CREEK RD
WEST TRENTON NJ
08628-1704
US

IV. Provider business mailing address

72 JACOBS CREEK RD
WEST TRENTON NJ
08628-1704
US

V. Phone/Fax

Practice location:
  • Phone: 609-462-0788
  • Fax:
Mailing address:
  • Phone: 609-462-0788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License Number25MA06643400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: