Basic Information
| Provider Information | |||||||||
| NPI: | 1235214008 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD, MSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 LANSDOWNE AVE | ||||||||
| Address2: | |||||||||
| City: | DARBY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190231200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6102372529 | ||||||||
| FaxNumber: | 6102375022 | ||||||||
| Practice Location | |||||||||
| Address1: | 41 MALL RD | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018051200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7817448000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| LastUpdateDate: | 10/19/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD071530L | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 210140 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02567586 | 05 | NY | MEDICAID |