Provider Demographics
NPI:1053508283
Name:GREG J. MERCURIO, MD, PA
Entity Type:Organization
Organization Name:GREG J. MERCURIO, MD, PA
Other - Org Name:CAUSEWAY MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:MERCURIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-427-8008
Mailing Address - Street 1:1720 STATE ROAD 44
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-8339
Mailing Address - Country:US
Mailing Address - Phone:386-427-8008
Mailing Address - Fax:386-423-0355
Practice Address - Street 1:1720 STATE ROAD 44
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-8339
Practice Address - Country:US
Practice Address - Phone:386-427-8008
Practice Address - Fax:386-402-4309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-02
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0060051207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDC6447OtherRR MEDICARE
FLE93959Medicare UPIN
FLF11110Medicare UPIN
FL12640SMedicare PIN
FL27109CMedicare PIN
FLK2663Medicare PIN