Healthcare Provider Details

I. General information

NPI: 1306381413
Provider Name (Legal Business Name): GREGORY MONROE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2016
Last Update Date: 12/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2503 E MICHIGAN AVE
JACKSON MI
49202-3757
US

IV. Provider business mailing address

2503 E MICHIGAN AVE
JACKSON MI
49202-3757
US

V. Phone/Fax

Practice location:
  • Phone: 517-788-9147
  • Fax: 517-395-4206
Mailing address:
  • Phone: 517-788-9147
  • Fax: 517-395-4206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License NumberPV0000000770798
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: