Individual
GREGG M EBERSOLE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
100 NAVARRE PL STE 4440, SOUTH BEND, IN 46601-1171
(574) 647-5300
(574) 647-5305
Mailing address
710 N NILES AVE, SOUTH BEND, IN 46617-1924
(574) 647-1610
(574) 237-6069
Taxonomy
Speciality
Code
Description
License number
State
207X00000X
Orthopaedic Surgery Physician
Primary
01079875A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
261970087
MEDICARE
IN
05
—
300013151
—
IN
Enumeration date
06/15/2011
Last updated
04/01/2021
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