Provider Demographics
NPI:1104028836
Name:GRIPE, AMANDA MELISSA (MD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MELISSA
Last Name:GRIPE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1026
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1026
Mailing Address - Country:US
Mailing Address - Phone:317-274-1201
Mailing Address - Fax:317-278-9905
Practice Address - Street 1:1111 RONALD REAGAN PKWY
Practice Address - Street 2:B1100
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-7085
Practice Address - Country:US
Practice Address - Phone:317-962-8067
Practice Address - Fax:317-962-3796
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01065106A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200925250Medicaid
INM400031450Medicare PIN