Provider Demographics
NPI:1144634650
Name:GREEN, ELIZABETH ANN
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:ANN
Last Name:GREEN
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 1:115 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:BATH
Mailing Address - State:NY
Mailing Address - Zip Code:14810-1508
Mailing Address - Country:US
Mailing Address - Phone:607-664-2255
Mailing Address - Fax:
Practice Address - Street 1:114 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:CORNING
Practice Address - State:NY
Practice Address - Zip Code:14830-2514
Practice Address - Country:US
Practice Address - Phone:607-937-6201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-12
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY16-6002567OtherEIN