Basic Information
| Provider Information | |||||||||
| NPI: | 1609435205 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | SAMANTHA | ||||||||
| MiddleName: | RAE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6600 VAN AALST BLVD BLDG 9250 | ||||||||
| Address2: | |||||||||
| City: | FORT BENNING | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319052102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7624082655 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6600 VAN AALST BLVD BLDG 9250 | ||||||||
| Address2: | |||||||||
| City: | FORT BENNING | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319052102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7624082655 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2019 | ||||||||
| LastUpdateDate: | 07/19/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 61277 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.