Basic Information
| Provider Information | |||||||||
| NPI: | 1306871769 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREWE | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1789 SHAWANO AVE | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543033243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204991428 | ||||||||
| FaxNumber: | 9204995808 | ||||||||
| Practice Location | |||||||||
| Address1: | 1789 SHAWANO AVE | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204991428 | ||||||||
| FaxNumber: | 9204995808 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 12/05/2017 | ||||||||
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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 | 2085R0202X | 30051-020 | WI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1018806004 | 01 | UNITED HEALTHCARE AMERICH | OTHER | 4838153 | 05 | MI | MEDICAID | 31476800 | 05 | WI | MEDICAID | 4838144 | 05 | MI | MEDICAID | P00287110 | 01 | RR MEDICARE | OTHER |