MEDICARE: MRS. DORET MAE GREEN MSED

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist
2	174400000X	Specialist		NY

General Provider Information

NPI Number	:	1104296094
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DORET MAE GREEN MSED

Provider Business Mailing Address
First Line	:	3547 PAULDING AVE
Second Line	:	P/H
City	:	BRONX
State	:	NY
Zip	:	10469-1316
Country	:	US
Telephone Number	:	347-427-1497
Fax Number	:

Provider Business Practice Location Address
First Line	:	3547 PAULDING AVE
Second Line	:	P/H
City	:	BRONX
State	:	NY
Zip	:	10469-1316
Country	:	US
Telephone Number	:	347-427-1497
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/05/2015
Last Update Date	:	10/05/2015

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