Individual
KEITH W GREEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
800 W 9TH ST, JASPER, IN 47546-2514
(812) 482-0643
(812) 482-0214
Mailing address
2061 W SKYVIEW DR, JASPER, IN 47546-8214
(812) 634-9504
(812) 634-9504
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
28138655A
IN
367500000X
Certified Registered Nurse Anesthetist
9261695
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000211953
ANTHEM BC ID
IN
01
—
163460047
MEDICARE PTAN
IN
05
—
200157750A
—
IN
01
—
28138655
INDIANA LICENSE
IN
01
—
940070020
MEDICARE PTAN
IN
Enumeration date
12/21/2006
Last updated
06/03/2024
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