=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659391506
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GREGORY ROBERT WARDA M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2006
-----------------------------------------------------
Last Update Date | 05/31/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2304 KOSSUTH ST BILLING OFFICE
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47904-3240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-446-9600
-----------------------------------------------------
Fax | 928-783-4257
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2304 KOSSUTH ST
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47904-3240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-446-9600
-----------------------------------------------------
Fax | 928-783-4257
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2080N0001X
-----------------------------------------------------
Taxonomy Name | Neonatal-Perinatal Medicine Physician
-----------------------------------------------------
License Number | 27466
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2080N0001X
-----------------------------------------------------
Taxonomy Name | Neonatal-Perinatal Medicine Physician
-----------------------------------------------------
License Number | C50724
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2080N0001X
-----------------------------------------------------
Taxonomy Name | Neonatal-Perinatal Medicine Physician
-----------------------------------------------------
License Number | 33879
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 2080N0001X
-----------------------------------------------------
Taxonomy Name | Neonatal-Perinatal Medicine Physician
-----------------------------------------------------
License Number | 01064039A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------