Provider Demographics
NPI:1942272828
Name:GREEN, ILEANA (MD)
Entity Type:Individual
Prefix:
First Name:ILEANA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 EAST RIVER DR.
Mailing Address - Street 2:5TH FLOOR
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-7301
Mailing Address - Country:US
Mailing Address - Phone:860-282-4133
Mailing Address - Fax:860-282-0170
Practice Address - Street 1:5 PERRYRIDGE RD
Practice Address - Street 2:PATHOLOGY DEPT.
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830
Practice Address - Country:US
Practice Address - Phone:203-863-3061
Practice Address - Fax:203-863-3846
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY203054207ZP0101X
CT52497207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG34122Medicare UPIN
NY468561Medicare ID - Type Unspecified