Provider Demographics
NPI:1205823390
Name:FACEMYER, GREGORY J (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:J
Last Name:FACEMYER
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 1:5121 MAHONING AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44515-1847
Mailing Address - Country:US
Mailing Address - Phone:330-799-3223
Mailing Address - Fax:330-270-8439
Practice Address - Street 1:5121 MAHONING AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44515-1847
Practice Address - Country:US
Practice Address - Phone:330-799-3223
Practice Address - Fax:330-270-8439
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-04
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35072943E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2125542Medicaid
OH0879802Medicare PIN
G95790Medicare UPIN