Provider Demographics
NPI:1063443273
Name:STANDAGE, GREGG PHILLIPS (MD)
Entity Type:Individual
Prefix:
First Name:GREGG
Middle Name:PHILLIPS
Last Name:STANDAGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 S REAY LN
Mailing Address - Street 2:
Mailing Address - City:THATCHER
Mailing Address - State:AZ
Mailing Address - Zip Code:85552-5417
Mailing Address - Country:US
Mailing Address - Phone:928-428-0144
Mailing Address - Fax:928-348-1375
Practice Address - Street 1:1515 S 20TH AVE
Practice Address - Street 2:
Practice Address - City:SAFFORD
Practice Address - State:AZ
Practice Address - Zip Code:85546-4009
Practice Address - Country:US
Practice Address - Phone:928-348-1370
Practice Address - Fax:928-348-1375
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2007-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMD22289207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ356586Medicaid
AZ356586Medicaid
Z28097Medicare PIN