Provider Demographics
NPI:1679763437
Name:MELLINGER, GREGORY (PA)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:MELLINGER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 PROVIDENT DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46580-3291
Mailing Address - Country:US
Mailing Address - Phone:574-372-5823
Mailing Address - Fax:
Practice Address - Street 1:1500 PROVIDENT DR
Practice Address - Street 2:SUITE A
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580-3291
Practice Address - Country:US
Practice Address - Phone:574-372-5823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-27
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99027179A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000592337OtherANTHEM
000000592337OtherANTHEM