MEDICARE: MR. GREGORY ROSS TYSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172V00000X	Community Health Worker

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2710230	OTHER	OH	PROVIDER I.D. NUMBER

General Provider Information

NPI Number	:	1104002237
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GREGORY ROSS TYSON

Provider Business Mailing Address
First Line	:	5871 FRANK RD NW
Second Line	:
City	:	NORTH CANTON
State	:	OH
Zip	:	44720-7543
Country	:	US
Telephone Number	:	330-497-6745
Fax Number	:

Provider Business Practice Location Address
First Line	:	5871 FRANK RD NW
Second Line	:
City	:	NORTH CANTON
State	:	OH
Zip	:	44720-7543
Country	:	US
Telephone Number	:	330-497-6745
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/18/2008
Last Update Date	:	01/18/2008

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