MEDICARE: GREGORY DETERS M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	036-087539	IL

General Provider Information

NPI Number	:	1497861702
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREGORY DETERS M.D.

Provider Business Mailing Address
First Line	:	1005 HEALTH CENTER DR STE 201
Second Line	:
City	:	MATTOON
State	:	IL
Zip	:	61938-4693
Country	:	US
Telephone Number	:	217-234-6055
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 RICHMOND AVE E
Second Line	:
City	:	MATTOON
State	:	IL
Zip	:	61938-4652
Country	:	US
Telephone Number	:	217-234-7000
Fax Number	:	217-238-5484

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/21/2006
Last Update Date	:	09/21/2018

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