Basic Information
| Provider Information | |||||||||
| NPI: | 1336127463 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREGORY | ||||||||
| FirstName: | JOE | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 435 S. CRYSTAL | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | BUTTE | ||||||||
| State: | MT | ||||||||
| PostalCode: | 597011506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4064963600 | ||||||||
| FaxNumber: | 4064963653 | ||||||||
| Practice Location | |||||||||
| Address1: | 435 S. CRYSTAL | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | BUTTE | ||||||||
| State: | MT | ||||||||
| PostalCode: | 597011506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4064963600 | ||||||||
| FaxNumber: | 4064963653 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2006 | ||||||||
| LastUpdateDate: | 10/22/2011 | ||||||||
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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 | 207R00000X | 2702 | AZ | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 12797 | MT | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 111097 | 05 | AZ | MEDICAID |