Basic Information
| Provider Information | |||||||||
| NPI: | 1033588256 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARK H GREGORY MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 445 | ||||||||
| Address2: | |||||||||
| City: | SULLIVAN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630800445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734686501 | ||||||||
| FaxNumber: | 5734686502 | ||||||||
| Practice Location | |||||||||
| Address1: | 555 N NEW BALLAS RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631416825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148728470 | ||||||||
| FaxNumber: | 3148728471 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2015 | ||||||||
| LastUpdateDate: | 09/17/2015 | ||||||||
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| AuthorizedOfficialLastName: | GREGORY | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3148728470 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 100578 | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.