Healthcare Provider Details

I. General information

NPI: 1033588256
Provider Name (Legal Business Name): MARK H GREGORY MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2015
Last Update Date: 09/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 N NEW BALLAS RD SUITE 101
SAINT LOUIS MO
63141-6825
US

IV. Provider business mailing address

PO BOX 445
SULLIVAN MO
63080-0445
US

V. Phone/Fax

Practice location:
  • Phone: 314-872-8470
  • Fax: 314-872-8471
Mailing address:
  • Phone: 573-468-6501
  • Fax: 573-468-6502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number100578
License Number StateMO

VIII. Authorized Official

Name: MARK GREGORY
Title or Position: OWNER
Credential: MD
Phone: 314-872-8470