Provider Demographics
NPI:1376740407
Name:PHIPPS, GREGORY RAY
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:RAY
Last Name:PHIPPS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2307 TURNBERRY DR
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-5094
Mailing Address - Country:US
Mailing Address - Phone:502-299-9555
Mailing Address - Fax:
Practice Address - Street 1:2307 TURNBERRY DR
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-5094
Practice Address - Country:US
Practice Address - Phone:502-299-9555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2020-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31003420A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100267020AMedicaid