Provider Demographics
NPI:1194926493
Name:GREGORY, ADAM M (MD)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:M
Last Name:GREGORY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3707 NEW VISION DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1702
Mailing Address - Country:US
Mailing Address - Phone:260-469-6602
Mailing Address - Fax:260-484-5919
Practice Address - Street 1:3707 NEW VISION DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1702
Practice Address - Country:US
Practice Address - Phone:260-469-6602
Practice Address - Fax:260-484-5919
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01058285A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00452683OtherRAILROAD MEDICARE
IN200870830Medicaid
IN219950D9Medicare PIN
IN924750EEMedicare PIN