Basic Information
| Provider Information | |||||||||
| NPI: | 1245337351 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREGORETTI | ||||||||
| FirstName: | SERGIO | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 28068 | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374248068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778991033 | ||||||||
| FaxNumber: | 4238925838 | ||||||||
| Practice Location | |||||||||
| Address1: | 1120 15TH ST | ||||||||
| Address2: | ROOM2144 | ||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309120004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067213873 | ||||||||
| FaxNumber: | 7067217763 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 06/15/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 046596 | GA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 339387 | 01 | GA | WELLCARE CMO | OTHER | G46596 | 05 | SC | MEDICAID | 612949974A | 05 | GA | MEDICAID | 612949974B | 05 | GA | MEDICAID | 950123 | 01 | GA | BCBS | OTHER | P00256115 | 01 | GA | RRMEDICARE | OTHER | 550789920 | 01 | GA | TRICARE | OTHER | 612949974D | 05 | GA | MEDICAID |