Healthcare Provider Details

I. General information

NPI: 1114966314
Provider Name (Legal Business Name): NICHOLAS J GREGO D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 JACKSON ST
PHILADELPHIA PA
19145-3712
US

IV. Provider business mailing address

424 MILL ST
BRISTOL PA
19007-4813
US

V. Phone/Fax

Practice location:
  • Phone: 215-826-8050
  • Fax: 215-826-8053
Mailing address:
  • Phone: 215-826-8050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS003907L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: