Basic Information
Provider Information | |||||||||
NPI: | 1922090182 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOJRAB | ||||||||
FirstName: | GREGORY | ||||||||
MiddleName: | G. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 485 | ||||||||
Address2: |   | ||||||||
City: | NEW CASTLE | ||||||||
State: | IN | ||||||||
PostalCode: | 473620485 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7655211516 | ||||||||
FaxNumber: | 7655993131 | ||||||||
Practice Location | |||||||||
Address1: | 152 WITTENBRAKER AVE | ||||||||
Address2: |   | ||||||||
City: | NEW CASTLE | ||||||||
State: | IN | ||||||||
PostalCode: | 473625000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7655993100 | ||||||||
FaxNumber: | 7655185365 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/15/2005 | ||||||||
LastUpdateDate: | 09/09/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/09/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 01034797A | IN | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 200026740 | 05 | IN |   | MEDICAID | 200311740F | 05 | IN |   | MEDICAID | 110215617 | 01 | IN | MEDICARE RAILROAD # | OTHER | 000000112527 | 01 | IN | ANTHEM PIN# | OTHER | 4044692 | 01 | IN | AENTA PIN# | OTHER |