MEDICARE: MS. CAROL MYRTLE GREEN PT

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	2251X0800X	Orthopedic Physical Therapist	3345	NC

General Provider Information

NPI Number	:	1326022344
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CAROL MYRTLE GREEN PT

Provider Business Mailing Address
First Line	:	4601 PARK RD
Second Line	:	SUITE 300
City	:	CHARLOTTE
State	:	NC
Zip	:	28209-3239
Country	:	US
Telephone Number	:	704-323-2000
Fax Number	:

Provider Business Practice Location Address
First Line	:	3541 RANDOLPH RD
Second Line	:	STE 100W
City	:	CHARLOTTE
State	:	NC
Zip	:	28211-1082
Country	:	US
Telephone Number	:	704-323-2000
Fax Number	:

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

Provider Enumeration Date	:	12/02/2005
Last Update Date	:	05/13/2010

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