Provider Demographics
NPI:1104002237
Name:TYSON, GREGORY ROSS
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:ROSS
Last Name:TYSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5871 FRANK RD NW
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-7543
Mailing Address - Country:US
Mailing Address - Phone:330-497-6745
Mailing Address - Fax:
Practice Address - Street 1:5871 FRANK RD NW
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-7543
Practice Address - Country:US
Practice Address - Phone:330-497-6745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-18
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2710230OtherPROVIDER I.D. NUMBER