Basic Information
| Provider Information | |||||||||
| NPI: | 1740224153 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REVEAL | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | T. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8450 NORTHWEST BLVD | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462781381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178022000 | ||||||||
| FaxNumber: | 3178022170 | ||||||||
| Practice Location | |||||||||
| Address1: | 8402 HARCOURT RD STE 125 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462602094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178022000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 03/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 01056443 | IN | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0801X | 01056443A | IN | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma |
ID Information
| ID | Type | State | Issuer | Description | 200381260 | 05 | IN | MEDICAID |