Provider Demographics
NPI:1124531702
Name:VILLAGE GREEN PRIMARY CARE, LLC
Entity type:Organization
Organization Name:VILLAGE GREEN PRIMARY CARE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER EMPLOYEE
Authorized Official - Prefix:
Authorized Official - First Name:ALLISON
Authorized Official - Middle Name:N
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-721-3822
Mailing Address - Street 1:1684 VILLAGE GRN LOWR LEVEL
Mailing Address - Street 2:
Mailing Address - City:CROFTON
Mailing Address - State:MD
Mailing Address - Zip Code:21114-2059
Mailing Address - Country:US
Mailing Address - Phone:410-721-3822
Mailing Address - Fax:410-451-0960
Practice Address - Street 1:1684 VILLAGE GRN LOWR LEVEL
Practice Address - Street 2:
Practice Address - City:CROFTON
Practice Address - State:MD
Practice Address - Zip Code:21114-2059
Practice Address - Country:US
Practice Address - Phone:410-721-3822
Practice Address - Fax:410-451-0960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-06
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
291U00000X
MDD0061041207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1455745077OtherNPI