Healthcare Provider Details

I. General information

NPI: 1467646125
Provider Name (Legal Business Name): EDWARD A GRECO JR MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2007
Last Update Date: 09/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

693 CONGRESS STREET
PORTLAND ME
04102
US

IV. Provider business mailing address

PO BOX 244
CAPE COTTAGE ME
04107
US

V. Phone/Fax

Practice location:
  • Phone: 207-774-6351
  • Fax:
Mailing address:
  • Phone: 207-774-6351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number5223
License Number StateME

VIII. Authorized Official

Name: EDWARD A GRECO JR.
Title or Position: OWNER MANAGER
Credential: MD
Phone: 207-774-6351