Healthcare Provider Details

I. General information

NPI: 1275675027
Provider Name (Legal Business Name): PHILIP GREEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 03/11/2020
Certification Date: 03/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

177 FT WASHINGTN AVE
NEW YORK NY
10032-3733
US

IV. Provider business mailing address

630 W 168TH ST BOX 4
NEW YORK NY
10032-3725
US

V. Phone/Fax

Practice location:
  • Phone: 212-342-3616
  • Fax:
Mailing address:
  • Phone: 212-342-3616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number253211
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number253211
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: