Healthcare Provider Details

I. General information

NPI: 1962485771
Provider Name (Legal Business Name): JIM GUS MEGREMIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2005
Last Update Date: 07/25/2022
Certification Date: 07/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10801 N MICHIGAN RD
ZIONSVILLE IN
46077-8170
US

IV. Provider business mailing address

10801 N MICHIGAN RD
ZIONSVILLE IN
46077-8170
US

V. Phone/Fax

Practice location:
  • Phone: 317-344-1234
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01042701A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: