Provider Demographics
NPI:1780783183
Name:ENNIS, GREGORY G (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:G
Last Name:ENNIS
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 3276
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47731-3276
Mailing Address - Country:US
Mailing Address - Phone:812-473-0181
Mailing Address - Fax:812-473-5822
Practice Address - Street 1:4100 COVERT AVE
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47714-5559
Practice Address - Country:US
Practice Address - Phone:812-476-9983
Practice Address - Fax:812-476-3809
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01051903A208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN610186900OtherFECA PIN
IN610186900OtherBLACK LUNG PIN
KY64003460Medicaid
IN145885OtherUMWA PIN
IN423127OtherHEALTHLINK NONPAR PIN
IN1761906OtherFIRST HEALTH PIN
IN064756OtherHAMP PIN
IN000000078150OtherBCBS PIN
IN610186900OtherBLACK LUNG PIN
IN147570Medicare ID - Type Unspecified
KY64003460Medicaid