Healthcare Provider Details

I. General information

NPI: 1275915928
Provider Name (Legal Business Name): AMANDA L GREENE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2015
Last Update Date: 12/23/2020
Certification Date: 12/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5320 W MICHAELS DR
APPLETON WI
54913-8446
US

IV. Provider business mailing address

5320 W MICHAELS DR
APPLETON WI
54913-8446
US

V. Phone/Fax

Practice location:
  • Phone: 920-882-8200
  • Fax: 920-882-8225
Mailing address:
  • Phone: 920-882-8200
  • Fax: 920-882-8225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberR-10331
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number70948-20
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number70948-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: