Provider Demographics
NPI:1649820788
Name:GREEN, SANDRA ROSE (MEDICAL TRANSPORT)
Entity type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:ROSE
Last Name:GREEN
Suffix:
Gender:F
Credentials:MEDICAL TRANSPORT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 SPRING VALLEY AVE
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-2944
Mailing Address - Country:US
Mailing Address - Phone:201-656-2350
Mailing Address - Fax:201-656-1719
Practice Address - Street 1:200 SPRING VALLEY AVE
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-2944
Practice Address - Country:US
Practice Address - Phone:201-656-2350
Practice Address - Fax:201-656-1719
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-19
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJG73056897951662207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0450406503Medicaid