Provider Demographics
NPI:1023147667
Name:GREEN, SUSAN MARY (M D MPH)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MARY
Last Name:GREEN
Suffix:
Gender:F
Credentials:M D MPH
Other - Prefix:DR
Other - First Name:SUSAN
Other - Middle Name:GREEN
Other - Last Name:GREGOIRE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD MPH
Mailing Address - Street 1:333 VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02842-7230
Mailing Address - Country:US
Mailing Address - Phone:401-619-1540
Mailing Address - Fax:401-619-1690
Practice Address - Street 1:333 VALLEY RD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:RI
Practice Address - Zip Code:02842-7230
Practice Address - Country:US
Practice Address - Phone:401-619-1540
Practice Address - Fax:401-619-1690
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI6309207R00000X, 2083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIC30978Medicare UPIN