Healthcare Provider Details

I. General information

NPI: 1760565402
Provider Name (Legal Business Name): SAMUEL DOUGLAS GREESON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 03/28/2022
Certification Date: 03/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7333 W JEFFERSON BLVD
FORT WAYNE IN
46804-6280
US

IV. Provider business mailing address

6920 POINTE INVERNESS WAY STE 200
FORT WAYNE IN
46804-7934
US

V. Phone/Fax

Practice location:
  • Phone: 260-458-3830
  • Fax: 260-458-3831
Mailing address:
  • Phone: 260-479-3516
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number01028597A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number01028597A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number01028597A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: