Healthcare Provider Details

I. General information

NPI: 1649286451
Provider Name (Legal Business Name): ANDREA ELIZABETH GREEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SOUTH PROSPECT STREET UHC PEDIATRICS
BURLINGTON VT
05401
US

IV. Provider business mailing address

239 RIDGE RD
CHARLOTTE VT
05445-9071
US

V. Phone/Fax

Practice location:
  • Phone: 802-847-4696
  • Fax:
Mailing address:
  • Phone: 802-425-7374
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number042-0010520
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: