Basic Information
| Provider Information | |||||||||
| NPI: | 1447200365 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KRESSE | ||||||||
| FirstName: | GREGORY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 879 | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727020879 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797137115 | ||||||||
| FaxNumber: | 4797137186 | ||||||||
| Practice Location | |||||||||
| Address1: | 146A PASSION PLAY RD | ||||||||
| Address2: | |||||||||
| City: | EUREKA SPRINGS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792539746 | ||||||||
| FaxNumber: | 4792532464 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | C5938 | AR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 52983 | 01 | AR | BLUE | OTHER |