Healthcare Provider Details

I. General information

NPI: 1700884004
Provider Name (Legal Business Name): GREGG A WELLS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2005
Last Update Date: 07/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 N WILSON DR
WEST UNION OH
45693-1577
US

IV. Provider business mailing address

PO BOX 711919
CINCINNATI OH
45271-0001
US

V. Phone/Fax

Practice location:
  • Phone: 937-544-1544
  • Fax:
Mailing address:
  • Phone: 866-286-5884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number35055354
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: