Basic Information
| Provider Information | |||||||||
| NPI: | 1386604460 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREGORY | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | JANE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4201 ST. ANTIONE UHC 6F MAILBOX# 226 | ||||||||
| Address2: | UNIVERSITY PEDIATRICIANS | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139665051 | ||||||||
| FaxNumber: | 3139660665 | ||||||||
| Practice Location | |||||||||
| Address1: | 3901 BEAUBIEN | ||||||||
| Address2: | CHILDREN'S HOSPITAL OF MI | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137455604 | ||||||||
| FaxNumber: | 3139660039 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2006 | ||||||||
| LastUpdateDate: | 01/04/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 4301053235 | MI | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0210X | 4301053235 | MI | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 4550680.10 | 05 | MI | MEDICAID |