Provider Demographics
NPI:1013124296
Name:GREEN, ALYSIA L (MD)
Entity Type:Individual
Prefix:
First Name:ALYSIA
Middle Name:L
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 1:801 ALBANY ST
Mailing Address - Street 2:FL G
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02119-3791
Mailing Address - Country:US
Mailing Address - Phone:617-414-6034
Mailing Address - Fax:
Practice Address - Street 1:915 COMMONWEALTH AVE REAR
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-1394
Practice Address - Country:US
Practice Address - Phone:617-358-3400
Practice Address - Fax:617-358-3710
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA232853207QS0010X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110076162AMedicaid
MA000178101Medicare PIN