Provider Demographics
NPI:1245217124
Name:GREEN, DORA RENEE (CRNA)
Entity Type:Individual
Prefix:
First Name:DORA
Middle Name:RENEE
Last Name:GREEN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19624 GOVERNORS HWY
Mailing Address - Street 2:SUITE 6 & 7
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-2077
Mailing Address - Country:US
Mailing Address - Phone:708-798-5838
Mailing Address - Fax:708-798-5865
Practice Address - Street 1:2600 GREENBUSH ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2477
Practice Address - Country:US
Practice Address - Phone:765-448-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.013944367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2247661Medicaid
728022OtherBUCKEYE
KY74006495Medicaid
IN000001092366OtherANTHEM PROVIDER NUMBER
000000196948OtherANTHEM BLUE SHIELD
IN300004136Medicaid
KY617576OtherWELLCARE
IN200371350Medicaid
OH2247661Medicaid
IN200371350Medicaid