Provider Demographics
NPI:1245242403
Name:GRIECO, GERARDO A (MD)
Entity Type:Individual
Prefix:
First Name:GERARDO
Middle Name:A
Last Name:GRIECO
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 1:1300 FRANKLIN AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-3592
Mailing Address - Country:US
Mailing Address - Phone:309-452-1193
Mailing Address - Fax:309-452-1349
Practice Address - Street 1:1300 FRANKLIN AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-3592
Practice Address - Country:US
Practice Address - Phone:309-452-1193
Practice Address - Fax:309-452-1349
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-061804208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-061804Medicaid
IL208392Medicare ID - Type Unspecified
ILD16239Medicare UPIN