MEDICARE: DR. ANDY GREEN DERMATOLOGY

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	207N00000X	Dermatology Physician

General Provider Information

NPI Number	:	1134463094
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR. ANDY GREEN DERMATOLOGY

Provider Business Mailing Address
First Line	:	1380 NE MIAMI GARDENS DR STE 270
Second Line	:
City	:	NORTH MIAMI BEACH
State	:	FL
Zip	:	33179-4721
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1380 NE MIAMI GARDENS DR STE 270
Second Line	:
City	:	NORTH MIAMI BEACH
State	:	FL
Zip	:	33179-4721
Country	:	US
Telephone Number	:	305-940-0701
Fax Number	:

Authorized Official
Title or Position	:	DERMATOLOGIST
Name	:	ANDY GREEN
Credential	:	M.D.
Telephone Number	:	305-932-4192

Provider Enumeration Date	:	11/16/2012
Last Update Date	:	11/16/2012

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