=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144233289
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAWRENCE J GREEN, MD LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/13/2006
-----------------------------------------------------
Last Update Date | 12/30/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15005 SHADY GROVE RD SUIE 440
-----------------------------------------------------
City | ROCKVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20850-6340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-610-0663
-----------------------------------------------------
Fax | 301-610-5420
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15005 SHADY GROVE RD SUITE 440
-----------------------------------------------------
City | ROCKVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20850-6340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-610-0663
-----------------------------------------------------
Fax | 301-610-5420
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DR. LAWRENCE J GREEN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 301-610-0663
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207NS0135X
-----------------------------------------------------
Taxonomy Name | Procedural Dermatology Physician
-----------------------------------------------------
License Number | D50346
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------