1467482034 NPI number — MARK S GRESLA M.D.

Table of content: MARK S GRESLA M.D. (NPI 1467482034)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467482034 NPI number — MARK S GRESLA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRESLA
Provider First Name:
MARK
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467482034
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 151
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DECATUR
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46733-0151
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-724-2145
Provider Business Mailing Address Fax Number:
260-728-3853

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
955 HIGH ST
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
DECATUR
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46733-2326
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-724-2125
Provider Business Practice Location Address Fax Number:
260-724-3859
Provider Enumeration Date:
07/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  01034460A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9131 . This is a "NO. IN PHP" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 100146990A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000087488 . This is a "ANTHEM PIN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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