Healthcare Provider Details

I. General information

NPI: 1063452225
Provider Name (Legal Business Name): CHERYL LYNN GREEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 04/15/2022
Certification Date: 04/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5444 GREEN ST
MURRAY UT
84123-5632
US

IV. Provider business mailing address

1755 W HIBISCUS BLVD # 215
MELBOURNE FL
32901-2616
US

V. Phone/Fax

Practice location:
  • Phone: 801-262-2647
  • Fax: 801-262-3897
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number331071-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberM-10273
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME133855
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: