Healthcare Provider Details

I. General information

NPI: 1104983162
Provider Name (Legal Business Name): GREGORY MAKRIS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 09/19/2024
Certification Date: 09/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 MADISON AVE FL 1
MOUNT HOLLY NJ
08060-2099
US

IV. Provider business mailing address

700 US RT 130 N SUITE 203
CINNAMINSON NJ
08077
US

V. Phone/Fax

Practice location:
  • Phone: 609-914-6000
  • Fax:
Mailing address:
  • Phone: 856-829-9345
  • Fax: 856-829-0580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number26NO06610700
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number26NJ00215000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: