Provider Demographics
NPI:1053392084
Name:GREEN, GRETCHEN ELIZABETH (MD)
Entity type:Individual
Prefix:
First Name:GRETCHEN
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 1:3186 VILLAGE DRIVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304
Mailing Address - Country:US
Mailing Address - Phone:910-486-5700
Mailing Address - Fax:910-486-5950
Practice Address - Street 1:3186 VILLAGE DR STE 201
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3979
Practice Address - Country:US
Practice Address - Phone:910-486-5700
Practice Address - Fax:910-486-5950
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012445272085R0202X
NC2006-007222085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5904067Medicaid
NC1053392084Medicaid
NC5904067Medicaid
NC2053307Medicare PIN