Provider Demographics
NPI:1124030127
Name:GREEN, REBECCA L (MD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
Last Name:GREEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:8200 W CENTRAL AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67212-9503
Mailing Address - Country:US
Mailing Address - Phone:316-722-6260
Mailing Address - Fax:316-721-8307
Practice Address - Street 1:8200 W CENTRAL AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67212-9503
Practice Address - Country:US
Practice Address - Phone:316-722-6260
Practice Address - Fax:316-721-8307
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
KS430254207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSP00182568OtherTRAVELERS MEDICARE
KSOOS22419OtherPREFERRED HEALTH SYSTEMS
KS104135OtherBLUE CROSS BLUE SHIELD
KS104135OtherBLUE CROSS BLUE SHIELD
KS104135Medicare ID - Type Unspecified