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General NPI Number Information
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NPI Number | 1073810453
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Entity Type | Organization
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Legal Business Name | GREENLINE MEDICAL CORPORATION
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Dates
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Enumeration Date | 02/19/2011
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Last Update Date | 02/19/2011
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Provider Practice Location Address
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Address Line | 804 BOMBAY LN
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City | ROSWELL
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State | GA
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Zip | 30076-5819
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Country | US
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Telephone | 770-754-9880
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Fax | 770-754-9881
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Provider Business Mailing Address
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Address Line | 804 BOMBAY LN
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City | ROSWELL
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State | GA
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Zip | 30076-5819
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. KIMBERLY GREEN
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Credential | D.O.
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Telephone | 770-754-9880
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208VP0000X
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Taxonomy Name | Pain Medicine Physician
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License Number | 058478
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 058478
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License Number State | GA
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