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General NPI Number Information
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NPI Number | 1235416918
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Entity Type | Organization
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Legal Business Name | GREGG P STANDAGE MD
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Dates
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Enumeration Date | 11/09/2011
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Last Update Date | 12/27/2011
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Provider Practice Location Address
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Address Line | 705 W HILLSIDE AVE
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City | PRESCOTT
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State | AZ
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Zip | 86301-1938
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Country | US
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Telephone | 928-348-1374
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Fax | 928-348-1375
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Provider Business Mailing Address
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Address Line | 1515 S 20TH AVE
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City | SAFFORD
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State | AZ
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Zip | 85546-4009
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Country | US
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Telephone | 928-348-1374
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Fax | 928-348-1375
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Authorized Official
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Title or Position | MD
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Name | DR. GREGG P STANDAGE
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Credential | MD
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Telephone | 928-348-1374
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 22289
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License Number State | AZ
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