Provider Demographics
NPI:1508920653
Name:GREEN, KEITH (CRNA)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2061 W SKYVIEW DR
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47546-8214
Mailing Address - Country:US
Mailing Address - Phone:812-634-9504
Mailing Address - Fax:812-634-9504
Practice Address - Street 1:800 W 9TH ST
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:IN
Practice Address - Zip Code:47546-2514
Practice Address - Country:US
Practice Address - Phone:812-482-0643
Practice Address - Fax:812-482-0214
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28138655A367500000X
FL9261695367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN28138655OtherINDIANA LICENSE
IN000000211953OtherANTHEM BC ID
IN200157750AMedicaid
IN28138655OtherINDIANA LICENSE