Healthcare Provider Details

I. General information

NPI: 1184746281
Provider Name (Legal Business Name): GERARDO A. GRIECO, M.D., S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 03/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 FRANKLIN AVE STE 210
NORMAL IL
61761-3588
US

IV. Provider business mailing address

1300 FRANKLIN AVE SUITE 210
NORMAL IL
61761-3592
US

V. Phone/Fax

Practice location:
  • Phone: 309-452-1193
  • Fax:
Mailing address:
  • Phone: 309-452-1193
  • Fax: 309-452-1349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: TAYLOR GRIECO
Title or Position: OFFICE MANAGER
Credential: R.N.
Phone: 309-452-1193