Provider Demographics
NPI:1093000366
Name:EBERSOLE, GREGG M (MD)
Entity Type:Individual
Prefix:
First Name:GREGG
Middle Name:M
Last Name:EBERSOLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:574-237-6069
Practice Address - Street 1:100 NAVARRE PL STE 4440
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1171
Practice Address - Country:US
Practice Address - Phone:574-647-5300
Practice Address - Fax:574-647-5305
Is Sole Proprietor?:No
Enumeration Date:2011-06-15
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01079875A207X00000X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300013151Medicaid
IN261970087OtherMEDICARE