Provider Demographics
NPI:1508822123
Name:MEGREMIS, THEODORE (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:
Last Name:MEGREMIS
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:PO BOX 4366
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47402-4366
Mailing Address - Country:US
Mailing Address - Phone:812-332-8242
Mailing Address - Fax:812-333-7684
Practice Address - Street 1:429 S LANDMARK AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-5003
Practice Address - Country:US
Practice Address - Phone:812-332-8242
Practice Address - Fax:812-333-7684
Is Sole Proprietor?:No
Enumeration Date:2006-04-22
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01020144A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100343900Medicaid
INP00114513OtherRAILROAD MEDICARE
IN300023777OtherRR MEDICARE
INP00114513OtherRAILROAD MEDICARE
IN542650AMedicare PIN
D94898Medicare UPIN
IN980210AMedicare PIN