MEDICARE: GARY A. MELLICK D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084S0012X	Sleep Medicine (Psychiatry & Neurology) Physician	DO1117	AL
2	2084N0400X	Neurology Physician	02006613A	IN
3	174400000X	Specialist	055142	GA
4	2084N0400X	Neurology Physician	DO1117	AL
5	2084N0600X	Clinical Neurophysiology Physician	DO1117	AL
6	174400000X	Specialist	34004503	OH
7	2084P2900X	Pain Medicine (Psychiatry & Neurology) Physician	DO1117	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1780641506
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GARY A. MELLICK D.O.

Provider Business Mailing Address
First Line	:	250 N SHADELAND AVE
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46219-4959
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2525 W UNIVERSITY AVE STE 502
Second Line	:
City	:	MUNCIE
State	:	IN
Zip	:	47303-3409
Country	:	US
Telephone Number	:	765-751-2600
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/26/2006
Last Update Date	:	01/14/2022

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Directions to “ GARY A. MELLICK D.O.” Practice Location

Language	Start Address	Practice Location

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