Basic Information
| Provider Information | |||||||||
| NPI: | 1114174265 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 955534 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631955534 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 12349 DE PAUL DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | BRIDGETON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630442512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142917900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2008 | ||||||||
| LastUpdateDate: | 11/19/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 49237 | AZ | N | Other Service Providers | Specialist | 207X00000X | 25MA09367900 | NJ | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | MD448629 | PA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 49237 | AZ | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0114X | 49237 | AZ | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery | 207X00000X | 2017006909 | MO | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | AZ | MEDICAID |