Healthcare Provider Details

I. General information

NPI: 1104028836
Provider Name (Legal Business Name): AMANDA MELISSA GRIPE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 01/28/2021
Certification Date: 01/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 RONALD REAGAN PKWY B1100
AVON IN
46123-7085
US

IV. Provider business mailing address

PO BOX 1026
INDIANAPOLIS IN
46206-1026
US

V. Phone/Fax

Practice location:
  • Phone: 317-962-8067
  • Fax: 317-962-3796
Mailing address:
  • Phone: 317-274-1201
  • Fax: 317-278-9905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01065106A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: