Healthcare Provider Details

I. General information

NPI: 1093718579
Provider Name (Legal Business Name): JIANAN GRAYBILL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 11/27/2023
Certification Date: 09/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7229 CLEARVISTA DR
INDIANAPOLIS IN
46256-1698
US

IV. Provider business mailing address

6626 E 75TH ST SUITE 500
INDIANAPOLIS IN
46250-2805
US

V. Phone/Fax

Practice location:
  • Phone: 317-621-5656
  • Fax: 317-621-4366
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number01040969A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: