Provider Demographics
NPI:1801063284
Name:GREENE, PEGGY S
Entity type:Individual
Prefix:
First Name:PEGGY
Middle Name:S
Last Name:GREENE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18109 PRINCE PHILIP DR
Mailing Address - Street 2:SUITE 325
Mailing Address - City:OLNEY
Mailing Address - State:MD
Mailing Address - Zip Code:20832
Mailing Address - Country:US
Mailing Address - Phone:301-774-8727
Mailing Address - Fax:301-774-8728
Practice Address - Street 1:18109 PRINCE PHILIP DR
Practice Address - Street 2:SUITE 325
Practice Address - City:OLNEY
Practice Address - State:MD
Practice Address - Zip Code:20832
Practice Address - Country:US
Practice Address - Phone:301-774-8727
Practice Address - Fax:301-774-8728
Is Sole Proprietor?:No
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX2426133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG02301M01Medicare PIN