Basic Information
| Provider Information | |||||||||
| NPI: | 1023061827 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JONES | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | ALLEN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 63308 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282633308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8649871611 | ||||||||
| FaxNumber: | 8649871611 | ||||||||
| Practice Location | |||||||||
| Address1: | 222 HERLONG AVE S | ||||||||
| Address2: | |||||||||
| City: | ROCK HILL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297321158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033291234 | ||||||||
| FaxNumber: | 8649871611 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 04/22/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | 36480 | SC | Y | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0202X | K8238 | TX | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 364803 | 05 | SC | MEDICAID | 104551004 | 05 | TX | MEDICAID |