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Michael Greene, M.D. Massachusetts License Applications

MICHAEL GREENE, M.D. MASSACHUSETTS LICENSE APPLICATIONS

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195 views57 pages

Michael Greene, M.D. Massachusetts License Applications

MICHAEL GREENE, M.D. MASSACHUSETTS LICENSE APPLICATIONS

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8453210
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© © All Rights Reserved
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REDACTED Cor py BOARD OF REGISTRATION IN MEDICINE seenevanse se Matai See TRSEELOW AND nTISAANEHGE SIDE OF fas soston wassactusetrsoaii1 — HRISHSU RR TE SREB STE eae AOA nr UST SARWENED ves- To QUESTIONS 15 1967-1869 Fu oUon se YoU Hust Suede sso ES PLEASE USe The ENCLOSED RETURN ENVECOPE Tease REA sama | re [ommoenmeme] rear i ae Tamme] Mont | ne FSPeeel ever | over Ruamuisnouey yao Sete ip PHEFEMAEDs SEDONA wo fa A204 $100 | 100 | ad 2d of Sheet ecerranue SS PAYABLE TO: COMMONWEALTH OF MASEACHUSETTS ASCHARL § GREENE ie yy TEN WE4T STREET, 26 FLOOR nw ioHAN AND Womens HospS SE igre.) 08TON, MASBACHUSETTS 02111 75 FRANCIS STREET a) EB ucASC mp rune on 00888 awe ae PAVED an YOU MUST READ THE NETRUGTIONS ENCLOSED WITH THs FORM TO ANEWEN QUESTIONS 10. 1. Printname: Michael F. Greene 12, Date of Birth: a mou senor SUNY Brooklyn wor [9 0.07) tcrekones 4 counry wore Mesea Soc enes, USA ator crunion: May 1976 | American Specialty Board Contiiog? [3B (Chek yes) Which @oerds? American Board Obstetrics & Gynecology 7. Princion! Speciatyiss; Maternal Fetal Medicine ___. Principat work sting: Brigham and Women's Hospital __ 1 peme srs: — 10. Proce buinmandcres: 25.Feancle Street Boston, MA O25 Brigham and Women's Hospital +1 etal agp at which you hav curently active prdiages: ‘2. Lat et oepil et which you hav als priviogas in tb pet 20 yous: ‘8, Sates ome than Mansachusts In whleh you ra presenti Hoenses to prectioe “4, Latany ote states wher you were praviously oenaad tract: Nome ves_NO) ‘None tay cnr cman api sunnah na wncan 1 so a nnn gegen tate © ARE yn her arty seemial ccd mace aerdanaegt ames | Eilat ives nd al tay che ae eh aly eae Yc rr nnn eve rb ne meine ae? 10, Hove you ever had any monte whioh Hes imped your ebiyt rection medicine rt funeon a a std’ of medi? 271, Have you sve ad an organi ness which hes impaired you ality te pratica medicine oo function as student of mene? 22, Arm you now, or have you Dou inte past dependent upon alzhel or Suge? 3, te you ee ory rete, at Aree Spery Gone Creston? St Fans outus ent atten by cov wet ma ipavesehasia 5 thaw compte ny CME auoment inh two o's orca on everett howe = 2. Laman ave [3] sche 7] pctonar (nu ony | HEREBY CERTIFY UNOER THE PENALTY OF PERJURY THAT ALL INFORMATION ON THIS FORM (FRONT AND BACK) INCLUDING ATTACHED SHEETS IS TRUE PURSUANT TO CHAPTE" 476 OF THE ACTS OF 105, 1 WL NOT CHARGE TO OR COLLECT FROM A MEDICARE BENEFICIARY 1WORE THAN THE MEDICARE REASCN: Kae Guahae SOA sennces” PURSUANT 70 ML. 626 4494, | CERTIFY UNDER T-e PENALTIES OF PERLIURY THAT |.TO MY BEST \NOWLEL ERIRAS AND PAD ALLSTATE YARED ReGUIRED UNDER LAW. BLEABE NOTE: THs APPLIES EVEN F Voge DEB) of Cae PELE, WAVE FILED ALL STATE TAX SSI phe GROUT OF THE COUNTEN. pare: (608 Revert ise) Massacre Dood of Regan In Medighe 146-1861 Renewal Applaton, Page 2012 Grea” ___ eguatn e 1 ile ue ane antec Phyo ast Name: ‘2a Sater te yume ne ead osc toot {2 b) nes wae ou peveudy wy emia npc BO | ten sootiea bev wth oe etomlgoutac —— ACTIE_™ ieiheeomerses pag? st.) hem cindy CALE game a yen cng Oe revel ate axe: ln afters a ee, awa) eres na cangest hw. puctoebezage [Den Rnctrorrovamin | ae Rana foun aToRaseoua Me! RTE ey nan rin rie enna NSUEIOER 3 ETENO CDN. nee taza tat’ Cit acai WIGS Tan RPO ST ACT ea tt apt sted BY mee wn Vas Basa TORR) NStenekveD NORECTINORECY PATENT CARE OTHE EXSMPTED__ (Sw ow, 14.9 Pwcenet Pacts Tne Mansctuete; 200% ‘unnons1stvugh 1 rt caitaetes oe, Cash altar YES ONO ath BG aveten, Prom OFM HA ACI ‘errant ete mn cn a ga eet tts rn 1 hv you baa elena any gang or ben pce oer bar. amare ob. i ras nga re et ec a {you enced YES a quetn 16, ot 17 provid ete cn Form 184 tacos ‘anon 18¥ugh mre aL on, Checkin YEEOrNO (etN/A ash ute. Proietti estas, Yan He SLL ERR a ace et eat gt nnn ‘a. nane youn 7 apteaintor armel ona ue ea mec ea fry 840 nsn nnn ‘23 Ham yout any eal nna ich bas pate ou sy pata ete a neon at tun ot mac 121 Have yu ha epi rus win asin you ayo prac mc erafurten ma aha ASCO 22. he yournon erhaeuten pat, perce pen Whole So 2a yuo ay oe, at Ata Specey Boul Cate 24 Ha youten die steno eer pei toute YES, a Bo ‘port ‘cm en ou piney ster, it gb or 9p ute ‘oor en La tm ayn tga al a ens rude Aon, ‘Sgr manual appa a be eo page aos a asm es pages ne Pamgaph sore sonar. ‘tata oy filo a a wach Your we cose Jou tt i Pon an obs ca ais copes mst pupost Exclos te $16) reali by emo cad cach, Moyo pol choked payee Coannenth Maat ‘apne gasry_SrSeNe spnsty_ichael, ney, 1.8) Oar ame any ht even ean ae ‘Brigham ang’ Wonen's Toepltal 2.) sou (ating 2.8 Asien ae} 4 Atos aia 2.0) teptore(aary (617) 753 _— 5852 0m ct ith (H0/OKRE_ {aco Seo Code ne Tn 2) roi, eeu Gast: 1976 BeOopne MOL 6. Coty, US, Caras Cade ere Tai | 2. ing Cad dete Poca et rte Ti) See eas ieee le Seer Ee Elon 7 Lacoe : geet eee en ; Seite 3 SRE : Te a eal telat : ers omar et gee ET TS ea Pesach ee ‘20Other eee 2 Seetty Code ae Tate 3 MEM pwca ct Maco Tine: 100 Spay Cate: 108 soc 10 0 he you encan Spy Bawa Cate? C/N) 1.8) ES ec we Bw Gauci Atngy Alemsrosey Bead Maen our ot Paste Sey ‘A Bomd ot ethan GB searser omerier & Oyrcciogy ‘Boars ot Paver Nin Ces Boson cel Supe, OF Beat Beart Peyetaty€heaogy De ous el Demat 8 Gear oped corny ‘owe doce? Ey beerd a Emnpury Mire © Baadot Owenrraseay ‘our Sey Fe Bosal Fant hatin PA Beadotatouey Bowe hence Sey (Bow the wc Pe Snaet reste Ss Senvotheuonges Grae Pun Beet Pye ci araeton "nary cry htt ageing WACTIE eau, el ot praca medina a Massechsai Prtuanite M.G4. 6475, wit charge ot slat Hoa 4 Medonre bane mae tanh Medoareoesonsbl charge or my bans ‘rv ih antares a pe earn ras heey arty nda he pena py Sat a ran one fo a swan Lee | ou 13,04 ‘Ten West Street, 3rd Floor, Boston, Massachusetts 02111 BAY qf ie ‘Commonwealth of Massachusetts Board of Registration in Medicine XN : 1991-1993 Physician Registration Renewal Appl Rightwation No. Statue 4254 ACTI 10/23/94 Dr. NICHAEL F GREENE URIGHAK AND WONENS HOSP 75 FRANCIS STREET 2OSTON® HA 02115~ + Guestons +7 hoe hf tm Board ft, Poa coret kas zea + Goere proce, pare ree eran toot 1 hnaweral nonoptonsunstoe conga. (The aocons spec hich qustons ae opera) a 1 Mata acopy ots fom endl atachmes or your own racrce-yos mt ge healthcare hes copies fo crctarpgS Te Bord char $200 ps posuge ores copy tried. < Enchua no $153.00 ranmaoy beans otto hack, money ero persona check made payable oe Conmerweat of Masacue ‘ety State: ‘am apiying to be registered withthe folowing staue: Active XX actve___ ‘hereby ceriy that i requesting Inactive status, | will not praction medicine in Massachusetts, Pre Printed Information ‘Corrections of Pre-Prinid information 1. Odvar Names), i ay. under which you were Hens: ero: = ! 2.8) Akos (Home) laderose: otytown_ state 2 JCounry Code;___(W 999 wte County) 2.b) Addoss (Business): iLGHAN AND WOMENS HOSP FRANCIS STREET D3Toxs MA O2T1S~ Country Code; (1060, writo County: 3. Date of ett sox: Dato of Brea Dry: ‘Sex (WF Uc. eeve Dete01/17/78 SNE: Uo, leave Osto(wor): yj est Telophone Number: Home ‘Busheas Home:(_ a 017) 732-5452 4 Medica! School CodoNYOG3 Your Graduated? 6 Degree: MD | Schoo! Code:____ Yaar Graduatod Dograe (MDiD0}._| ‘Name of Schoo. 1199000, weta Schock eae atate University of New York Downstatel#edical ctr 1.0) Otir States whara you ara ow lcensod t practice (ADEs: eee ae eeaeecee Sep +} Sttos whore you prowoualy wore lceneed 1o practice (AbE»; See ae eae rege seeCe TE 18, Spociaty Codos) (See Table 9 ‘Sade Hours. por Wook a Mase, New Q Maternal ang Fetal Kedicline a 7a) Ave you American Specialy Board Ceriied? (YINJY 7b) YES, Enter odes Goto: IG Hoare of Obstetrics ana Gynecology | Code cose coo 8. ru Lease Hor) an pen) Feel EA, bow my D604 so yovtnet Le Ssewiuaa 4. tam eongdny CME naioons nto ym png ymin, ven er ani ‘(fou mus fitout teparaie Waiver Form. The walver must bo grated by the Board befor your feense willbe renewed.) Sea lastuctons for CME requirments. Do nct submit documentation of your CME's with your ronawa) apicaton. ‘0m 9190 -Pe19671 For Otic Use Only: Waiver Grant, Dato_/ 1 FILL IN NAME AND NUMBER: a * Sea QREEINE roperinro:4 2.0.3.4 ak ates aoa auemmcarne NC ow enacrcrn tien aes uinioar__C RL C_O- Anornativoly,ineicaa as flows: | am roisioning wilh ACTIVE siti, bull am not covered by odical malpraccn Insurance because lem (@heck one) (QNOT INVOLVED IN OIRECTANUIRECT PATIENT CARE: (W) OTHERWISE EXEMPT (State how ottarnise exam 11. Cunt Hospital Aftatons (Supe te codbs om Table Sand pace a chock mak nae toa faa whore you hav ania prvlegoe (AP). Fecay cove: ALi MAr) —Fcsy Cod SAP) Facility Code: /_(AP) Facility Code: AP) Faciity Code: _—!IAP) Facility Code:_____/_{AP) 11900, wa0 Nar gor! Nexis ich you amiga rge and tor Hal Cay Flo wih ich ou wor noid pnt yan Frcily Code:___—Faclty Cad:___——Faity Codes —Faaity Code: 17900, wto Nancie 12 Poet rant Tring lo Mateachunat (MA) (Sebo oct) 1) Ao you currnty in a post graduating program a MA a a rosiant or cba felow? You___ No_DX (Chock ona.) 2) HyouBoinaMA program, aryoua |) Rosient_ Cina Fetow_— or) Ragauch Felow__? [Chuck na) €) How ary hous par Wp weak you span ine MA poet radu ang pogan?___frahk a MA. 18, Cara of Pationts in Massachucots (MA) (S99 insrucion book) 10 1) How many hours por ypical week ae you curenily invoked In ovpatontcare in MA? rs uk. a MA, 'b) How many hour por typical woek re you curonilyinvohed in inpationt cara in MAP, rk a MA 14. Prindpal Work Sting. '2) Whatis you pinipal wor sting? (See Tabi | O ‘Quostions 15 through 22 reter tothe past four vets only. Check elther VES or NO (not N/A) to gach question. Provide deals on Form 16A. ‘for tothe Insuction booklet fr acdonel ofomation. Me 16, Hae any pending oF new mecioal malpractice clim boon made against you whather or nota lawsuit was fled in relation t the alm)? 16, Have you buen @ defendant in any pancing or nw riminel proceeding othr than a minor talc offense... 17, Ara any formal ciptaary charges pending ot has any cecipinary acon (as dtined by Board equatons--Soe inaruction) boantakon sate youby ary goverment aso, hepa tar hel car ac, oF cso mati msocaon Graton, tcl ‘Sate or lca. 18, Has your privdoge to possess, dsponsa or pracciba consoled eubetances been suspend, revoked, denied, rested, surondared, ‘or hve you boon calod before ar boon warned by tis stato anyother uriediton noudeg a federal agency?.. 16. Have jou wtekawn an apploaton for medial tooee or boon deniad a medal Keene or any eakon? 20, Have youhad any mena ness which hes inpired your eit pracion medicine orto function as a student of mein. 21, Hav youhad an onan ieaus which has impate your bly to pracoe medicine oft fncton a a student of made. 22, Ar you now, oF have you boon In ho past our your, dopendort upon alcohol or crue? Pursuant 19 M.G.L 6475, will nt charge too collect from « Medicare beneficiary more than the Medicare reasonable charge for my services. Puraunt to M.G.L. 0.620 sec.49A, | certty Under the penalties of perjury that, te my best knowledge and belief, Ihave fied any Maveschuitesiste ‘ax raturne und paid ony Meseaohusets state taxes, that are required under law. NOTE: This applies even If you reside out-of-atate or out of the country. {cary that wi fut my obligetion to report ebuse or neglect of children pureuant to MLG.L. 0.110 600.518, ‘hereby certy under the penalties of perry that all Information on this form and Form 1SA\s rue, woun Medal $ Atte om 13,9) 7 ‘Commonwealth of Massachusetts Board of Registration in Medicine : ‘Ten West Street, 3rd Floor, Boston, Massachusetts 02111 1993-1995 Physician Registration Renewal Application RegistsionNo. Sus Foe Lae Fee ci: spade 1ycay os “Skee Wiating Adivoax Tess (aig) WICIKAL FO GREENED abe HAM AND WORENS HOS Som: ea ae Sera see Country Code (See Table 1 Directions: Staple check to Bottom of form. Add late fee I necessary. *Quetons 18 include formation fom Bowd les, Please cores ss necestery in the boxes ‘rovded on the righthand sie ofthe page. “efor: procedicg, please read the ntti booklet. Some qestons ae opto + Make a copy ofthis form and al utachments for your own records - you wil ned copies : forcredettling and other purposes. The Board wil charge «fer fr cach copy i provides Fe Srcceaaeeaer repo + alone he $250.00 renewal ee by mear of eerie cheek mney ode or personal check made inp { eyble athe Commonwealth of Masiacuseas, shemescnnncmenssnnned Pre Pristed information Corrections of Pre Printed Informton 1, Other name(s, i any, under which you were Reese Name: 2 o) Adress (Home Adress ome CiyrTown: State; Fis County Gade 16989 print Coane oats Bsn sain ais HAW AND WUKENS 4O5h Conny Cade F999 print Com 7s FRAUCTS STREET Safou, 94 Gat15 3 a Duc ofRich MDIY: LL Sexy _| ne se Lic. sue Dute(MDY: SS Le Issue Date: 01/17/73 SH eee Tetephone Number: Home: Busines: Home Business it COT737 52-5432 Fall Nane uf Medica Schoo 4. Name of Metical School stite University of New York Downstate Mecical Cer Your Graduates Desres (MDIDOY Yess Gradanted:? 0 Degree: 19 5. 1) Othe sates where you ae now licensed to practic (Abb: Spear see Cae ea 5) States where you previously were icensed to pacts (ABE = eee Cate ous pez Week a Maw 6, Speciahy Codes (Seo Table 2 ee Cos _Hous per Weck in Mass, = fre S Haternal ans Fetal meatcind OS mama + J 17. a) you are curently American Specialy Board Ceiied, enter Codes: (See Tuble 3) Code: 95 Code: Code: Code: "by Ifyou previously were American Spectlty Board centfied, but are no longer. please enir codes of prior centification: (See Table 3) Code: Codes Code: Cade: 8. Drug License Number(s). if any: 2) Federal (DEA) Federal (DEA) b) Sta (Ma) Suse (MAY: 9, Thave completed my CME requirements in the two years preceding my renewal date: Yee No, waiver requested ‘You must fll out a separete Waiver Form. The waiver must be granted by the Board before your Hisense willbe renewed. See inaction: for (CME requirements. Do not submit documentation of your CMEs with your renewal application ae PRINT NAME AND NUMBER: ryscia tuntine QREENE Registration Nunta: “12034 10, Activity Status: 1am applying to be registered with the following stams: Active XC Inactive + Thereby certify that if requesting Inactive status, I will not practice medicine, including writing prescriptions, ln Maseachusetts, 11 My medical malpractice insurance is covered x (©) INSURANCE CARRIER _X or (b) LETTER OF CREDIT._If applicable, chock ne. Lis lowe CR Aberatvely, indicate ax follows: Lam regisring with ACTIVE sais, bu an nt covered by medial apace insurance Bocuse Ta (Check One): () NOT INVOLVED IN DIRECTINDIRECT PATIENT CAREIN MASS: (i) OTHERWISE EXEMPT: (Sutehow otherwise exempt: 12. Curent Helin Cze Facil Aflitions. Suply te codes from Table 4 and place a check mark nent hoe faites where you have saniing pegs (AP. Facility Code: 2k wh (AP) Facility Code: | (AP) Fairy Code: ___ (ap) Frey Code: / (AP) Pally Cote AP) aslo ———) ah ‘1£999, print name(s): ‘kon oma which you rovy bel vig ander elo ar ie wid wichyou wee wlan pt? (Gor Tale rat cate 14D. rug cate Psy Cole: — ay Coe Pty 16999, write name(s): —2J- OL LA) 13, Are youcurenty na pos graduate waning ona in MA ma resent or cine felow? Yeu. NaX Cheskone) 14, a) Whatis your principal work seing? (See Tae s) LO. ) Care of patents in Massechusets (MA) (See instruction booklet) 10 i) How many hours per typcel week ae you curently involved in oupatien caren MA? LO exwicin MA low many hours per iypiel week are you curently involved in ipatizn’ cere in MA? LD) extvicia MA Questions 15 through 23 refer a.the past ra searaonly, Check cither YES or NO (NOT N/A) to cach question. Provide deuils on Form 1SA forall YES answers. Refer to the instnsction booklet for addtionel information, "AST TWO V1 IN THE PAST TWO YEAI ye ce 15. Has my medical malpractice claim been made against you, whether or not lawsuit was filed in relation tothe elim? 16, Have you been charged with any criminal offense, oher than a minor taffc Violation’. 17. Have you formally been chasged with or discipned for any violation of the rules, by-laws or standards of practice of any governmental authority, health care feclity. group practice or professinal sociey or assocation?... 18, Hes your privilege to possess, dispense or prescribe contolled substances been surendored ta or suspended, revoked, denied ‘or restricted by any ste or federal agency? i 18. Have you withdrawn an epplictin for a medial icense o-~n denied a medica license for any reason? 20, Have you had any mental ilinets which has impaired your ability to practice medicine orto function as «student of medicine? 21. Have youhad en organi illness which has impaired your ability to practice medicine or to function as «student of medicine? 22. Ase you now, or have you been inthe past two years, dependent upon alechol or drogs? 23, Has my professional lability insurance provider restricted, limited, terminated or imposed «surcharge on your coverage?... + Pursuant to G.L. c. 112, see. 2,1 will not charge toor collect from a Medicare beneficiary more than the Medicare reasonable charges, + Pursuant to G.L. c.62C, sec. 49A, Lhereby certify under the penalties of perjury that, to the best of my knowledge and belle, Thave ‘led all Massachusetts state tax returns and pald all Massachusers state taxes that are required under law. NOTE: ‘This applies even if jou rskde out-of-tate or out ofthe country. +" Thereby certify that I will full) my obligation to report sbuse or neglect of children pursuant 10 G.Ls ¢, 119, s8¢.S1A, + Thereby certify under the penalties of perjury that all Information on this form and Form 1SA is true, coun Aithuh f Fecing ue FEE ‘Commonwealth of Massachusetts Board of Registration in Medicine ‘Ten West Street, 3rd Floor, Boston, Massachusetts 02111 1995-1997 Physician Registration Renewal Application RegneatonN, Sane Tae ReewalDus Las Fes $250.00 525.00 Correction of Malling Adress 42034_active $50 9/23/95. tog ‘Malling Adarens ‘Adsiens (Mailing): VINCENT MEM. OBSTET. ASSOC. MICHAEL F GREENE, M.D. - VINCENT MEM. OBSTCL.ASSOC Sree 32 FRUIT ST, FNDRS.4, #426 Coa BOSTON, MA 02114 See Directions: Refore proceeding, please read the insruetion booklet. Some questions are optional, + Failure to renew in thnely manner will cause your Ucense to lapse and may affect your able to practice medicine In the Commonwealth, (See enclosed letter). + Add ate fee if necessary, + Make a copy ofthis form and all uttachments for your own record - you will need copies for redensaling tnd other purposes, The Board will charge a fesfor each copy it provides. + See inszuetions on detachable coupon st botiom ofthis page. MEMIMINE Pre-Printed Information Corrections of Pre-Printed Information 1. Other name(s), if any, under which you were licensed: 2Home Address: Address oo Zip: i Counzy i a i awe | Ue. Teue Due: 92747/78 88h Lie Isvve Date QD: dS Home: Basins: Home Phone: ‘Business Phone iL) c (617)726-2770 Pull Name of Medical School:, 4. Name of Medical School: State University of New York Downstate Medical ctr Yeur Graduated: Degree (MDIDO}: Yeu Greduated\76 Degree: MD = 5. 6) Oter es where you ae now license to practice (Abb == States where you prevouly ware oensed to prec (AB): —_— 6. Specialty Codes) (See Table 1): eee Hows per Week in Maes ‘Code Hours per Week in Mass, MFM 0 Maternal and Fetal Medicin OS, print specialty: 7. Ifyou ae curently American Specialy Bourd cerifieg, enter codes: (See Table 2) Code: 9g Cote: 4 Drug license numbers) ifany: 4) Federal (DEA) ) Massachsens Federal DRAW Mass 9. Activity Situs: Tam applying tobe registered wit the following sumus: ACTIVE EK. INACTIVE __. + Thereby certity that f requesting Inaetive status, I wil not practice medicine, including waiting prescriptions, In Mossachusetts. PRINT NAME AND NUMBER: Piysiint Last Nane: GREENE Regiseation Number: 42034 10. a) Current health care facilityties) at which you have completed the credentialing process for the provision of patient care, Supply the ‘codes from Table 3 and place a check saark next to those facilities where you have sdmitting priviloges (AP). city Code: LGB SZ (ap) Fuclty Code: ——— (AP) Fay Code: AP) Frcitiy Code: 021} (ap) FailiyCode: (AP) Fry Code: — —(AP) 17998, pein names): 1) Adina hospital at which you previously beld privileges and otber health ewe aces with which you wee asocstd ithe pst 2 years (Gee Table 3) Facility Code: 9 2. L. Facitty Code: 99 9 Pacitity Code; ____Faciity Code: ______ Facility Code: 119, we name(s JOSLIN CLpzG 111. My medics! malpractice insurance is covered by (a) Insurance Ceicr X_ (b) Letierof Credit. __ If applicebe, check one. List fsurer: _ORTCO Atrnsivey indicates follows: Tam zegisuring with ACTIVE sats, but Tam ot covered ty medial malpacice insurance because Tan (Check One): () Not involved in iectndzet paint cze in Maseachusets: (4) Omerwise exermp: —— Satehow otherwise exempe: 12, Are you currently in a post-graduate training program in Mass. as n resident or clinical fellow? Yes __ No (Check one) 13. a) What is your principal work setting? (See Table 4) 1 0 ') Care of patients in Massachusets (See insrction booklet.) |) How meny hours per typical week are you curently involved in ouipatent care in Mess? — 20. tra/wk i) How many hours per typical week are you currently involved in inpatient care in Mass? AQ. hesiwi ©) Approximately what percentage of your patient care hours are in primary care? (Gee insmuctions for definition of primary exe) 9 % ‘Questions 14 through 24 refer tothe past two years only. Check either YES or NO (NOT N/A) to each question. Provide deus on Forms R-1 end R-2 forall YES answers, Refer tothe Insiructlon booklet for additonal information an definitions. THE PAST TWO YEARS: YES NO 14, CLATMS MADE: His any medical malpractice claim been mace against you which as nt yet been finally seed or ‘adjudicated, whether or no await was fled in relation othe claim? 15. CLAIMS RESOLVED: Has any medictl malractiveclnim against you been sled, adjudicated or atherwise resolved, ‘whether or no lawsuit was filed in relation to the cen? 16, Has any loves, otter than a medica malpetce al, whch ila to your compeiency to prectce madicne or you Pro fessione conduc inthe practice of medicine, ben filed against you by a patient of been sted, adjudicted or otherwise sed? enn 19. Have you ben charged with any criminal ofense, er than minor tac ilo é 18, Heve you been formally charged with or disciplined for any violation ofthe rules, by en out fps sovemmentl authority, health care esl, group pace or professional society or ssacaion? 18. your ee pomen, dps ps ost snes br edd pene revoked deed or resricied by any state or federl agency? 20, Have you withdrawn an application fora medial eene cr been deed a medial eee for any cease? 21. Mas any rofesonal ay ieuenc provider esice ine einaed or impoue a srcharge on your caren or fre you volar acd edar mint or insrance coverage in espns waning y= rots ty insurance provider? 22. Have you been diagnosed wih or do you have a medial condion which Limite or imps your aby fo pace medicine 23. Heve you engaged inthe use ofeny chemical substance(s) which in eny way interfered with your ability 0 practice? nn 24 Hee youvoluatymodied or aera your ope of prac of edn for my retson oer than emai eandiod? sone 25, Lave complead my CME roqiements inthe two years precoding my renewal deta You No, taining rogram exemption (ee insrucion bolle). ——— frequesting awaiver you mus fill ouza sopaate Waiver Form, ‘The waiver must be grand bythe Board before your licens wil be ‘enawed. See instructions for CME requirements. Do not submit documentation of your CME with your renewal sppiction. + Pursuant to G.L.c. 112, sec. 2, Twill not charge to or collet from a Medleare beneficlary more than the Medicare reasonable charges. + Pursuant to G.L.€.62.C, sec. 49A, Fhereby certify under the palos and pense of perjury that, tothe best of my knowledge and bel, 1 have fled all Massachusetts state tx returns and paid all Massachusetts sate taxes that are required under law. NOTE: This applies ven if you reside out-of-state or out of the United States, ‘+ Pursuant to G.L.c. 112, sec. 1A, hereby certify that I wil full! my obligation to report abuse or neglect of children as required by GL. 19, 514. a ac ofp o aia rer A No, waiver requesed 2012.00 eat 1. PHYSICIAN INFORMATION MICHAEL. F. GREENE, First Name “Middle initial Last Name Suffix M.D. ‘Meakin ae ev : Mass License #42034. First Issue Date 01/17/78. License Status... Active, Hospital Af Vincent Mem. Obstet Assoc ‘Massachusetts General Hospital 82 Fruit SiFndrs.4,#426 ‘Mount Auburn Hospital Boston, MA 02114 USA. (617) 726-2770 Meike adress conrecions here: Make ans corrections co above here Delate."Mount,.Auburp. Hospital” case Insurance Plan A filiaion: s . ee — 1. Baystate | Accepting New Patents? BYes LiNo 2. §MO Blue ne | 3."Blue Care ieee - ~ [As mei ves Cine Ay Tufts. ——_-—____-~ esl 5. Medicaid (Please correc as necessary) 6. Neighborhood Health Hi. EDUCATION & TRAINING State University of New York Downstate Medical Ctr MD 76 Medical Sahoo! See eee Digiee™~ F Dai : Make corrections here Beaton Hospital, for Womens Obstetrics..& Gynecology.07/76 s HE End. 96/80 ‘Residences Progranis) Start Brigham_and Women's Hospital, Fellowship Maternal Fetal Medicine 07/80... Fai 08/82. ‘Residency Program(s) Siarv Reiidency Programs) ‘Siar A, SPECIALTY BOARD CERTIFICATION Primary Specialty: Maternal and Fetal Medi Certifying Board Name: Board of Obstetrics and Gynecology Secondary Specialty Centifving Board Neme: Make any corrections here Make any corrections here: Primary:..Obstetries and. Gynecology. Board Name: American Board Obstetrics & Gynecology Secondary: Naternal Fetal Medicine "4 American Board Obstetrics & Gynecology, ‘Division Maternal Fetal Medfetne Board of Registration in Medicine Physician Profile 9012.00 IV. BOARD DISCIPLINE Final Decisions and orders issued by the Massachusetts Board of Registration in Medicine Nature Date ‘Board Action NONE, Vl. CRIMINAL CONVICT ‘The Board of Registration is unable to obtain accurate data for this category at the present time. This information will be included when the court system is fully computerized. Please list any eriminal convictions, Include conviction date and nature of complaint... NONE. sunny ~ a ~ ~ ~ Vil. MALPRACTICE No.of Years in Practice: # 16 ' Details of claims paid for Dr. GREENE i eee rit. igo 3090; 09, et | 2.8/1 908 7 Amount Paid 4aRQGEBCOG Ss Basis for Complain: Ovetttaissewdare! Oe ee ee Amount Paid Basis for Complaint “~"” > Date “Amount Paid z Basis for Complaint Date Amount Paid Basis for Complaint on Date ‘Amount Paid Basis for Complaint i Date “Amount Paid ‘Basis for Complaint PHYSICIAN HONORS & PEER-REVIEWED PUBLICATIONS Please enter any peer-reviewed publications fo which you have contributed and any awards for community service or professional recognition you have been given. __ Awards, Honors Publications Outstanding Teacher of Operative 1, Greene MF, Alred EN, Leviton A, Maternal metabolic * Sas ontrOT ai TOK watery’ arong Thtanis OT Cbetic Obstetrics, Brigham and Women's Hospital, mothers. Diabetes Care, 1995;18:166.9. Sareea 2 Calla “SE, Finer ‘SL, “Christiansen” GL,” Greene 19B9. ANE, 1993... nec sonar ME, Crowley. 1..WE,...The. economic. impact. of multiple : {gestation pregnancies and the contribution of assisted- : aeieaiey -repeoduction.techniques-t- their incidence. —-N-Engl-}- Med : 1994:331:244.9. een ae - 30--Greene: MF;-Benacerraf B:~-Prenatal diagnosis“ dhbetic gravidas: uflty of ultrasound and maternal serum alpha- fEtoptotelit screening. Obstet Gyiiecdl T9977: 520-4 Note: Please return the survey in the enclosed envelope to: Atlantic Associates, Ine., 8030 South Willow Street, Manchester, NH 03103 Board of Registration in Medicine Physician Profile : Commonwealth of Massachusetts Board of Registration in means P| ‘Ten West Street, 3rd Floor, Boston, MA 02111 (617) 727-3086, ext. 320 Physician Registration Renewal Application a f Before proceeding, please read the instruction booklet. + Copy this form and all attachments for your own records; you will need copies for credentialing and other purposes ‘The Board will charge «fee for each copy. + Remit $280.00 for renewal fe. + Return renewal application In GREEN envelope, + Add late fee of $28.0, if necessary. + Enclose check with coupon in BLUE envelope, Regisirition No 42034 Renewal Date: 10/23/97 1. Actviy Status: Active Retiring. (se instructions) (Checkenlyone) Inactive *(4ee below) [J Do not wish to renew 2. Other Name(s), ifany, under which you were Hiensed Corrections ((ype or print) Other Name(s ee es i i. A)Mailing/Business Address: MICHAEL F GREENE, M.D. Malling Address VINCENT MEM OBSTET ASSOC City/Town: ‘State: 32 FRUIT ST,FNDRS.4, #426 ‘ BOSTON, MA 02114 ip: __ Country B) Home Address: 1.1 1997 [Other Address: Cityrrown: State Zip: County eee ome; 7 Home Phone: ny ) Business Business Phone: (617) 726-2770 pierre Date of Birth (M/D/Y) Sex (MIF) a prunes be Diset M Lic. Issue Date (M/D/Y) SSH: je, fsue Date — ae Full Name of Medica! Schoo! 5, A)Name of Medical School: State University of New York SESE ecans canon Downstate Medical ctr : ) Year Graduated: 76 C) Degree: MD Year Graduated: ____ Degree (MD/D0}: 6, Specialty Code(s) (See Table 1) ours Per Week in Mass, Code(s) Hours per Week in Mass y ows 0BG 70 «Obstetrics and Gynecology BPS SO Noe GS MEM 0 Maternal and Fetal Mediei|itOs, Print Specialy; — 7. Current American Board of Medical Specialties Certification (See Table 2) Code: 0G — Code: o@ Code: Code: OO 8, Drug License Numbers, if any : ‘A) Federal (DEA): Leo B) Massachusetts: is 9. A) Other states where you are now licensed to practice Abbr: Abbr: B) States where you previously were licensed to practice Abbr: Abb “If requesting Inactive status, you agree not to practice medicine, including writing prescriptions, in Massachusetts PRINT NAME AND NUMBER: LastName GCC ONO. Registration Number“ O24 10, A. Curent health cee facilites at which you have completed the credentialing process forthe provision of patent care. Supply the codes ftom ‘ate and pce ghegk mak nx owe heehee elie whte eve emi prlego (AP) tctiy cel Sister) Pity Cole tar) Frality Code;___ (AP) Frei Cove tan) Prelly Cole — Frelity Coe ar) 1999, print namie B._ Additional health care facilites at which you previously held privileges or with which you were associated in the past two (2) yeas, (Sce Table 3) aslty Code Pasty Code:__Fuity Code:__FcltyCode:___aciy Codes__ 11999, write Name(s: Eeeeseeede secs 11, My medica malpractice insurance is cover by a) 4“ Insurance Curie __b) Leter of Credit Name of laure: 2 g Altematively, indicate as follows: { em registering with Active status but I am not covered by medical malpractice insurance because {am (check one) Please explsin exemption Not involved in ditecVindiect patient care in Massachusetts b)___ Otherwise exempt 12, Are you euently in a post-graduate raining program in Mass asa resident or clinical fellow? (check one) 13. A, What is your principal work setting? (See Table 4)_\_ 8, Care of patients in Massachusets (Se instruction booklet) 1) Average weekly hour involved in 2) outpatient care QCD test —b) inpatient are AC) nevi 2) What is the approximate percentage of your patient care hours in primary care? _C)_% PARTA ‘Questions 14 through 22 refer to the past tno @2)_years only, Check either VES or NO (NOT.N/A) to each question, Prov Form R for rence i Olek for 3 information and sefinitions, IN THE PAST TWO (2) RS: YES NO] 4, CLAIMS MADE: Has any medical malpractice csim been made against you that has not yet been finaly setled oF adjodicated, whether or not a lawsuit was filed in relation 1 the claim? 15. CLAIMS RESOLVED; Has any medica! malpractice laim that has been made sgsinst you been settled, adjudicated, ar otherwise resolved, whether or not lawsuit was filed in relation tothe claim? 16, Has any lawsuit, other than a medical malpractice suit, which is related 10 your competency to practice medicine, or your professional conduct in the practice of medicine, been fled egainst you or been setid, adjudicated or otherwise resolved? 17. Have you been charged with any criminal offense, other than a minor traffic violation? 18, Have you been formally charged with or disciplined for any violation ofthe rules, by-Iews or standards of practice of any ‘governmental authority, healthcare facility, group prectice or professional sociciy ot association? 19. Has your privilege to posses, dispense or prescribe controlled substances been surrendered to or suspended, revoked, ‘denied or retrited by any site oF federal agency? 20, Have you withdrawn an application fora medical license or been denied a medical license for any reason? 21. Has any professional ibility insurance provier restricted, limited, terminated, imposed a surcharge oF co-payment, OF placed any condition related to profesional competency or canduet on your coverage or have you valuncrly restricted, {imited or terminated your insurance coverage in response to an inquiry by a professional liability insurance provider? 22. Have you completed your CME requirements preceding your renewal dat (see instruction bookley? Waiver requested (waver fore due 306898 prio dae of cease expiats). [) Trang Program exemption ‘See Instructions for CME fequirements. Do not submit documentation of your CMEs with your renewal application. 277 CONTIYURD ON PAGE 3. ALL QUESTIONS ON PART-B MUST BE ANSWERED. (ala sel | Ano = ome FS ISY Signature Commonwealth of Massachusetts Board of Registration in Medicine ‘Ten West Street, 3rd Floor, Boston, MA 02111 (617) 727-3086, ext. 320 Physician Registration Renewal Application & Before proceeding, please read the instructlon booklet. ‘+ Copy this form und al attachments for your own records; you will need copies for eredentaling and other purposes, + Remit $250.00 for renewal fee + Return renewal appleation + Add late fee of $25.00, if necessary. + Enclose check with coupon ion Renew conaeaae Regiemation Ne 42034 ate 10/23/1999 i AC ‘Ifyou want to change your current status, please indicate below: (Check one). Dl Active CRetiring (cee instructions) Cimactive (6ee below *) do ng 2. Other Name(s), if any, under which you were licensed: Aeted ‘corrections (type or print) iter Name § 4) MailingBusiness Address: Maing Adress: MICHAEL F GREENE. City/Town: Bia VINCENT MEM OBSTET Assoc : aa 32 FRUIT ST FNDRS 4 #426 ze: f BOSTON, MA 02114 8) Home Address: omer Address. Cieyowa: Se zip Seon ‘Home Phone: Basiness Phone: 4. A) Date of Birth: sex B) SS#: Full Name of Medical Schoo! 5. A) Name of Medical School: ‘State University of New York Downstate Medical Ctr B) Year Graduated: 7, CyDearee: yp Year Graduated: Degree: [] M.D. DO. 6 Speciaty Codes) (See fable 1) : Sade) "Hours Per Week ix Massachisets ‘Sode(s) Hours por Weck in Mass, 20 Bs OBG 0 Obstetrics and Gynecology A Sg See eee eee MEM 0 Matera and Fetal Medicine IF 08, Print Specialty: 7. Coment American Board of Medics! Species Cerfcation (See Table 2) Codes Code Code: Code: 593 §, png Leendert any" ao ‘A) Federal (DEA): Mass: 1B) Massachusets: : 9. A) Other states where you are now licensed to practice ‘Abbr: Abbe: BB) States where you previously were licensed to practice ‘Abbr: “If requesting Inactive status, you agree not to practice medicine, including writing prescriptions, in Massachusetts. 6 PRINT NAME AND NUMBER: LastNine:_ @ RE ENE Registmton Number 4 2 O13 Y 10, Current healthcare facilities at which you have completed the credentialing process forthe provision of patient care, Supply the codes from Table 3 and place a check mark next to those health care facilites where you heve adrnitting privileges (AP), Next to ‘each facility, write the approximate percentage of patient care hours that you provide in each facility . Pact Caled (AR)_ _/__(AP)_% Facility Code (AP) % Facility Code: (AP) 1 (aP)___% Facility Codes (AP) 1999, print name(s): 11, My medical malpractice ingurnce is covered by ) P&L Insurance Carer b) [] Lett of Credit Name of Insurer: cf Altematively, indicate as follows: ‘am registering with Aetive status but Iam not covered by medical malprectice insurance because Iam (check one) 5 OM in direevindiect patient care in Massachusetts &) [] Otherwise exerapt Please‘explalt tion” 12, Are you curently ier postgraduate trening program in Massachusetts asa resident or clinical fellow? (check one) 13. A. What is your pringipal Work setting? (See Table 4) _{ © B, Care of patent in Massachusetts (se intretion booklet). 1) Average weekly hours involved in: 1) outpatient care QO hriwk 6 2) What is the approximate percentage of your patient care hours in primary care? Has nny medical malpractice claim been made against you that has not yet been finally settled or adjudiceted, whether ornot a lawsuit was fled in relation tothe claim? 15. CLAIMS RESOLVED: Has any medical malpractice claim that has been made against you been settled, { adjudicated, or otherwise resolved, whether or not a lawsuit was filed in relation tothe claim? 16, Has any lawstit, other than a medical malpractice suit, which is related to your competency to practice medicine, or yout professional conduct in the practice of medicine, been filed against you or been settled, adjudicated or otherwise resolved? 17. Have you been cherged with any criminal offense, other then a minor trafic violation? 18, Have you been formally charged with or disciplined for any violation of laws, rules, by-laws or standards of practice of any govemmental authority, health cere facility, group practice or professional society or association? 19. Has your privilege to possess, dispense or prescribe controlled substances been surrendered to or suspended, revoked, denied or restricted by any state or federal agency? 20. Have you withdrawn an application for a medical license or been denied 2 medical license for any reason? 21. Hes any professional libilty insurance provider restricted, limited, terminated, imposed a surcherge oF co-payment, or placed any condition related to professional competency or conduct on your covernge or have ‘you voluntarily restricted, limited or terminated your insurence coverage in responso to an inquiry by & professional lability insurance provider? 22, CMI CERTIFICATION: Have you completed your CME requirements preceding your renewal date? JRE Yes (] No 1 CME Waiver requested (CME waiver form duc 30 days prior to date of license expiration) DD CME exemption See Instructions for CME requirements, Do not submit documentation of your CMEs with your renewal application. + Pursuant to G.ts¢. 112, § 2,1 will mot charge fo or collect from a Medicare beneficiary more than the Medicare fe schedule amount," + Partuant to G.L. .62C, §49A, to the best of my knowledge and bell, Ihave fied all Massachusetts stato tax returns and pald all “Massachusetts state taxes that are required under law. NOTE: This apples even ifyou reside oubof-state or out ofthe United States. ‘+ Pursuant to G.L. , 112, § 14, wil fulfll my obligation to report abuse or neglect of children as required by GL. 119, §StA. + Thereby certify under the penaltles of perjury that all the Information on the Renewal Application and Form R is true, sine Meu £ Cee o — ove 1/5199 YOU MUST SIGN AND INCLUDE PART. B, WITH YOUR RENEWAL APPLICATION Commonwealth of Massachusetts Board of Registration in Medicine Ten West Street, 3rd Flor, Boston. MA 02111 (617) 727-3086 lps avsmedboard.org = * Physician Registration Renewal Application ~ Before proceeding, pl need copies for credentialing and other pu areen envelope £ weeks before your renew t {or your own records; you will Uform with attachments must be returned in the + Remit $250.00 for renewal fee. + Add late fee of $25.00, if necessa Please review carefully the following tnjOraeBsdscMadicite ach and completeness. Make any corrections or alterations as required. 1 Current Stans: gctive Registration No 49954 Renewal Date: 19/93/2901 If you want to change your current stams, please check gne of the following boxes wo indica active (Retiring (see instructions) Ditnactive (see instructions) 1) Do not wish wo renew Please make corrections (type o: prini) your new status: (Check only onc) 2, Other Name(s), if any, under which you were licensed Biker Nae 3. A) Mailing/Business Address: Mailing Address: MICHAEL T GREENE cyto Sai VINCENT MEM OBSTET assoc : SOFRUIT ST INDRS 4 436 ep: Coun BOSTON, MAG2114 a ) Home Adress: eee Te rip encrenne cee Tone ASS eiyrtovr Home Phone one piano Business Phone: groyra4.2009 PLEASE NOTE: No P.O, Box addresses for home or busines dares, 7. amen Amsco Bod of Mica! Spcialis Gas Se Tobe 4 2) Dae ofBith sen ee esse 8 Drug License Nurnbers, ifuny: 5. al Name of Medial School 2) Feeral (DEA) eee ‘b) Massachusetts: by vEUPGHAIAEER'Y of Nem York page Medical Cr 9 Ouher states where you a 10w licensed to practice (Abbr.) 1976 6. Specialty Code(s) (See Table 1) See ategeeeee da tegeree eet tae Code(s) Hours ner Week in Mass. ) States where you were previously licensed (Abbe) OBG 0 Obstetrics and Gynecology TTT ae MEM _0___Matermal and Fetal Medicine 10. Curteat health care facilities at which you have completed the eredenrialing process forthe provision of patient care. (Supply the codes from Table 3 and place a check mark next to those health care facilites where you have adinitaug privileges (AP), Next to each facility, write the approximate percentage of patient care hours tbat you provide in cach facility), Facility Code: ( @ Pi jl ‘an lO 10 2% Facility Code: /__(AP)_% Facility Code:____ Facility Code —— % Facility Code ——/ (a) 9 Facility Code 1999, pris nant) ae ary % (ar) 6 PRINT YOUR Last NamE: © {4E E PUE _____ License numer: YAU SY 1. My medical malpractice insurance is covered by a) JX Insurance Carer b) C) LenerofCredt = + = * : Name of tesurer t ‘Alternatively, indicate 2s follows, 7 | aan registering with Active status but Iam not covered by medical malpractice insurance because I am (check one) a) C) Not involved in direcvindirect patient care in Massachusetts >) [[] Otherwise exempt Please explain exemption ai a 12. Are you currently in a post-graduate training program in Massachusetts as a resident or clinical fellow? (check one) C] Yes $R(No 13. A. What is your pincipal work sing? See Tabled) fC) feces ee nae ata oo ip ee ae ae ge eg Meee ero ese Set npas nt OTs ze T! we YEAI 14, CLAIMS MADE: Has any medical malpractice claim been made against you that has not yet been finally Settled or adjudicated, whether or nota lawsuit was filed i relation tothe claim? 15. CLAIMS RESOLVED: Has any medical malpractice claim that has been made against you been settled, adjudicated, or otherwise resolved, whether or nota lawsuit was filed in relation tothe claim? 16, Has any lawsuit, other than a medical malpractice suit, which is related to your competency to practice medicine, «or your professional conduct in the practice of medicine, ben fled against you or been settled, adjudicated or otherwise resolved? 17. Have you been charged with any criminal offense, other than a minor traffic violation? 18, Have you been charged with or disciplined for any violation of laws, rules, by-laws or standards of practice of ‘aay governmental authority, healthcare facility, group practice or professional society or association? 19, Has your privilege to posses, dispense or prescribe controlled substances been suspended, revoked, denied, restricted by, or surrendered to any state or federal agency? 20, Have you withdrawn an application for a medical license or been denied a medical license for any reason? 21, Has any professional liability insurance provider restricted, limited, terminated, imposed a surcharge oF ! ‘co-payment, or placed any condition related to professional competency or conduct on your coverage or have ‘you voluntarily restricted, limited or terminated your insurance coverage in response to an inquiry by a professional Kabilty insurance provider? 22: CMECERTIFICATION? Have you complete your CME rEquicements preceding your newal date?” PRYes—L] No C1 CME Waiver requested (CME waiver form due 30 days prior o date of license expiration) Cl CME exemption ‘See Instructions for CME requirements. Do not submit documentation of your CMEs with your renewal application. Pursuant 10 GL. ¢. 112, §2 will wot charge tor callet froma Medicare beneficiary more than the Medicare fee schedule amount Pursuant to Gil. ¢.62C, §49A, tothe best of my knowledge and belief have filed all Massachusetts state tx returns and pald all Massachusetts state taxes that are required under law. NOTE: This applies even i you reside out-of-state or out ofthe United States. + Pursuant to Gl 6. 626, §47A, to the best of my knowledge and belief, Iam in compliance with M.G.H.C. 119A relating to withholding and remitting Child Support. + Parowant to Ga, 112,614, 1 will fell my obligation 1 report ebuse or neglect of children as required by G.L. & 119, 1A. land Form R is true. © Thereby certify under the penalties of perjury that all the information on the Renewal Applicati Signatue: Keelarl Ln owe FLY Of MAKE A COPY OF YOUR APPLICATION AND ALL ATTACHMENTS BEFORE MAILING. — 2 Commonwealth of Massachusetts Board of Registration in Medicine 560 Harrison Avenue, Suite #G-4, Boston, MA 02118 —

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