Healthcare Provider Details

I. General information

NPI: 1023147667
Provider Name (Legal Business Name): SUSAN MARY GREEN M. D. M.P.H.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SUSAN GREEN GREGOIRE MD MPH

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 05/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 VALLEY RD
MIDDLETOWN RI
02842-7230
US

IV. Provider business mailing address

333 VALLEY RD
MIDDLETOWN RI
02842-7230
US

V. Phone/Fax

Practice location:
  • Phone: 401-619-1540
  • Fax: 401-619-1690
Mailing address:
  • Phone: 401-619-1540
  • Fax: 401-619-1690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number6309
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number6309
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: