Provider Demographics
NPI:1649286451
Name:GREEN, ANDREA ELIZABETH (MD)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:ELIZABETH
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 1:239 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:VT
Mailing Address - Zip Code:05445-9071
Mailing Address - Country:US
Mailing Address - Phone:802-425-7374
Mailing Address - Fax:
Practice Address - Street 1:1 SOUTH PROSPECT STREET
Practice Address - Street 2:UHC PEDIATRICS
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401
Practice Address - Country:US
Practice Address - Phone:802-847-4696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0010520208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1009409Medicaid
VTBCBS59221Medicare UPIN