Healthcare Provider Details

I. General information

NPI: 1285738690
Provider Name (Legal Business Name): GREGORY MELLOR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2006
Last Update Date: 10/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6701 TELEGRAPH RD
ST. LOUIS MO
63129
US

IV. Provider business mailing address

161 WASHINGTON ST EIGHT TOWER BRIDGE, SUITE 1400
CONSHOHOCKEN PA
19428-2083
US

V. Phone/Fax

Practice location:
  • Phone: 866-825-3227
  • Fax: 484-351-3800
Mailing address:
  • Phone: 866-825-3227
  • Fax: 484-351-3800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number097908
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: