1114421575 NPI number — DR. KRYSTAL ALEXANDRIA GREEN MD

Table of content: DR. KRYSTAL ALEXANDRIA GREEN MD (NPI 1114421575)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114421575 NPI number — DR. KRYSTAL ALEXANDRIA GREEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREEN
Provider First Name:
KRYSTAL
Provider Middle Name:
ALEXANDRIA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114421575
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/30/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
134 BRIDGETON PIKE STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MULLICA HILL
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08062-2616
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-507-2783
Provider Business Mailing Address Fax Number:
856-221-4138

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2148 N 2ND ST STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILLVILLE
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08332-1304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-641-6272
Provider Business Practice Location Address Fax Number:
856-327-6588
Provider Enumeration Date:
03/21/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  25MA10935000 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com