Provider Demographics
NPI:1871581546
Name:GREEN, MARJORIE A (MD)
Entity type:Individual
Prefix:DR
First Name:MARJORIE
Middle Name:A
Last Name:GREEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:11 RUTLEDGE RD
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:MA
Mailing Address - Zip Code:02478-3322
Mailing Address - Country:US
Mailing Address - Phone:617-489-6169
Mailing Address - Fax:
Practice Address - Street 1:725 CONCORD AVE
Practice Address - Street 2:SUITE 4100
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-1040
Practice Address - Country:US
Practice Address - Phone:617-864-8822
Practice Address - Fax:617-547-5367
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA47577207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0138568Medicaid
MAB72524Medicare UPIN
MAB11707Medicare ID - Type Unspecified