Healthcare Provider Details

I. General information

NPI: 1023147683
Provider Name (Legal Business Name): ROGER GREEN, M.D., PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PINE WEST PLAZA, BLDG. #1 WASHINGTON AVENUE EXTENSION
ALBANY NY
12205
US

IV. Provider business mailing address

10 EVERGREEN LN
WOODSTOCK NY
12498-1621
US

V. Phone/Fax

Practice location:
  • Phone: 518-464-9999
  • Fax: 518-464-9650
Mailing address:
  • Phone: 518-464-9999
  • Fax: 518-464-9650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080S0012X
TaxonomyPediatric Sleep Medicine Physician
License Number179477
License Number StateNY

VIII. Authorized Official

Name: DR. ROGER D GREEN
Title or Position: MD OWNER
Credential: MD
Phone: 518-464-9999