Healthcare Provider Details

I. General information

NPI: 1063718625
Provider Name (Legal Business Name): ALLISON M GREENE PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2011
Last Update Date: 07/02/2024
Certification Date: 07/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 E WESTERN RESERVE RD
POLAND OH
44514-3358
US

IV. Provider business mailing address

100 DEBARTOLO PL STE 200
YOUNGSTOWN OH
44512-6095
US

V. Phone/Fax

Practice location:
  • Phone: 330-726-3204
  • Fax: 330-729-9316
Mailing address:
  • Phone: 330-729-8146
  • Fax: 330-965-5229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.003204
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: