Provider Demographics
NPI:1720235401
Name:FARIS, GREGORY W (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:W
Last Name:FARIS
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:720 ESKENAZI AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5187
Practice Address - Country:US
Practice Address - Phone:317-630-7276
Practice Address - Fax:317-656-4216
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-25
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01073676A207P00000X, 207PE0004X, 208000000X, 2080P0204X
OH35.097527208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200640016OtherMEDICARE PTAN
IN264430206OtherMEDICARE PTAN
IN201060680Medicaid