Healthcare Provider Details

I. General information

NPI: 1104878982
Provider Name (Legal Business Name): GREGORY SCOTT MASIMORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 12/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 EXECUTIVE PARK DR STE A
GREENWOOD IN
46143-3213
US

IV. Provider business mailing address

730 EXECUTIVE PARK DR STE A
GREENWOOD IN
46143-3213
US

V. Phone/Fax

Practice location:
  • Phone: 317-346-7246
  • Fax: 317-543-3763
Mailing address:
  • Phone: 317-346-7246
  • Fax: 317-543-3763

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number01042621A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number01042621A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: