Provider Demographics
NPI:1942383310
Name:GREEN, STEPHANIE KARAHALIS (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:KARAHALIS
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 1:45 GERALD RD
Mailing Address - Street 2:
Mailing Address - City:MARBLEHEAD
Mailing Address - State:MA
Mailing Address - Zip Code:01945-2069
Mailing Address - Country:US
Mailing Address - Phone:781-631-0320
Mailing Address - Fax:781-990-3300
Practice Address - Street 1:45 GERALD RD
Practice Address - Street 2:
Practice Address - City:MARBLEHEAD
Practice Address - State:MA
Practice Address - Zip Code:01945-2069
Practice Address - Country:US
Practice Address - Phone:781-631-0320
Practice Address - Fax:781-990-3300
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA72819207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3082318Medicaid
MAF00931Medicare UPIN
MA3082318Medicaid