Provider Demographics
NPI:1336109412
Name:PHELPS, GREGORY L (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:L
Last Name:PHELPS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4411 OAKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37416-2367
Mailing Address - Country:US
Mailing Address - Phone:423-892-4289
Mailing Address - Fax:423-553-1818
Practice Address - Street 1:4411 OAKWOOD DR
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37416-2367
Practice Address - Country:US
Practice Address - Phone:423-892-4289
Practice Address - Fax:423-553-1818
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD027356207QH0002X, 207Q00000X, 2083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0447283Medicaid
TN1501013Medicaid
GA000579268AMedicaid
TN3808658Medicaid
441504OtherGROUP CCN
TN0447283Medicaid
TN103I117787Medicare PIN