Basic Information
| Provider Information | |||||||||
| NPI: | 1780783183 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ENNIS | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3276 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477313276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124730181 | ||||||||
| FaxNumber: | 8124735822 | ||||||||
| Practice Location | |||||||||
| Address1: | 4100 COVERT AVE | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477145559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124769983 | ||||||||
| FaxNumber: | 8124763809 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 04/20/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 01051903A | IN | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 610186900 | 01 | IN | FECA PIN | OTHER | 610186900 | 01 | IN | BLACK LUNG PIN | OTHER | 64003460 | 05 | KY | MEDICAID | 145885 | 01 | IN | UMWA PIN | OTHER | 423127 | 01 | IN | HEALTHLINK NONPAR PIN | OTHER | 1761906 | 01 | IN | FIRST HEALTH PIN | OTHER | 064756 | 01 | IN | HAMP PIN | OTHER | 000000078150 | 01 | IN | BCBS PIN | OTHER |