Basic Information
| Provider Information | |||||||||
| NPI: | 1437440187 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GEHRES | ||||||||
| FirstName: | KYLE | ||||||||
| MiddleName: | JEREMY | ||||||||
| NamePrefix: | |||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6626 E 75TH ST STE 500 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176219312 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1402 E COUNTY LINE RD | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462270963 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178877000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2011 | ||||||||
| LastUpdateDate: | 09/17/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | DO1570 | SC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 02005434A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 300015480 | 05 | IN | MEDICAID | P02198172 | 01 | IN | MEDICARE RR | OTHER |