=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093000366
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GREGG M EBERSOLE M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2011
-----------------------------------------------------
Last Update Date | 04/01/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 NAVARRE PL STE 4440
-----------------------------------------------------
City | SOUTH BEND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46601-1171
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-647-5300
-----------------------------------------------------
Fax | 574-647-5305
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 710 N NILES AVE
-----------------------------------------------------
City | SOUTH BEND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46617-1924
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-647-1610
-----------------------------------------------------
Fax | 574-237-6069
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 01079875A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------