1518429836 NPI number — ELLEN WALFORD GREEN MD

Table of content: ELLEN WALFORD GREEN MD (NPI 1518429836)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518429836 NPI number — ELLEN WALFORD GREEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREEN
Provider First Name:
ELLEN
Provider Middle Name:
WALFORD
Provider Name Prefix Text:
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:
1518429836
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4107B BIOINFORMATICS 130 MASON FARM ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHAPEL HILL
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27599-7080
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-966-2514
Provider Business Mailing Address Fax Number:
919-966-6842

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4119B BIOINFORMATICS BUILDING 130 MASON FARM ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHAPEL HILL
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27599-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-966-2514
Provider Business Practice Location Address Fax Number:
919-966-6842
Provider Enumeration Date:
04/04/2019

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: 390200000X , with the licence number:  PG205825 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 390200000X , with the licence number: RS2022-0794 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 390200000X , with the licence number: 2023-01815 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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