Basic Information
| Provider Information | |||||||||
| NPI: | 1326043597 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAVRELIS | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | GEORGE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8558 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | MERRILLVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464107032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193927084 | ||||||||
| FaxNumber: | 2197036854 | ||||||||
| Practice Location | |||||||||
| Address1: | 3800 SAINT MARY RD STE 304 | ||||||||
| Address2: | |||||||||
| City: | VALPARAISO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463833986 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199476795 | ||||||||
| FaxNumber: | 2197036896 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2005 | ||||||||
| LastUpdateDate: | 08/24/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 01030831A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 100138640A | 05 | IN | MEDICAID | 9115389 | 01 | IL | ANTHEM BC/BS | OTHER | 110044491 | 01 | IN | RAILROAD MEDICARE | OTHER | 000000085027 | 01 | IN | ANTHEM BC/BS | OTHER |