Provider Demographics
NPI:1083983647
Name:MICHAEL J. GREGSON, M.D., P.A.
Entity Type:Organization
Organization Name:MICHAEL J. GREGSON, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:GREGSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PA
Authorized Official - Phone:208-232-8300
Mailing Address - Street 1:PO BOX 4907
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83205-4907
Mailing Address - Country:US
Mailing Address - Phone:208-232-8300
Mailing Address - Fax:208-232-8303
Practice Address - Street 1:1950 E CLARK ST
Practice Address - Street 2:SUITE C
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-3314
Practice Address - Country:US
Practice Address - Phone:208-232-8300
Practice Address - Fax:208-232-8303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-27
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM3289174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty