Healthcare Provider Details

I. General information

NPI: 1669665824
Provider Name (Legal Business Name): STEPHANIE ANNE GREEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2007
Last Update Date: 08/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

488 VANDERBILT PKWY
DIX HILLS NY
11746-5853
US

IV. Provider business mailing address

488 VANDERBILT PKWY
DIX HILLS NY
11746-5853
US

V. Phone/Fax

Practice location:
  • Phone: 631-427-7013
  • Fax:
Mailing address:
  • Phone: 631-427-7013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number157814-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: