Provider Demographics
NPI:1013986926
Name:KONRATH, GREGORY A (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:A
Last Name:KONRATH
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 1:285 W 12TH ST
Mailing Address - Street 2:STE 106
Mailing Address - City:PERU
Mailing Address - State:IN
Mailing Address - Zip Code:46970-1653
Mailing Address - Country:US
Mailing Address - Phone:765-472-8041
Mailing Address - Fax:765-475-8956
Practice Address - Street 1:285 W 12TH ST
Practice Address - Street 2:STE 106
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-1653
Practice Address - Country:US
Practice Address - Phone:765-472-8041
Practice Address - Fax:765-475-8956
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01049739A207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200343390AMedicaid
IN200212630Medicaid
IN200212630Medicaid