Provider Demographics
NPI:1336117852
Name:NEILLEY, GREGORY S (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:S
Last Name:NEILLEY
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 1:454 OLD STREET RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:PETERBOROUGH
Mailing Address - State:NH
Mailing Address - Zip Code:03458-1200
Mailing Address - Country:US
Mailing Address - Phone:603-924-4680
Mailing Address - Fax:603-924-4977
Practice Address - Street 1:454 OLD STREET RD
Practice Address - Street 2:SUITE 301
Practice Address - City:PETERBOROUGH
Practice Address - State:NH
Practice Address - Zip Code:03458-1200
Practice Address - Country:US
Practice Address - Phone:603-924-4680
Practice Address - Fax:603-924-4977
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH8060207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30002991Medicaid
B69652Medicare UPIN
NHRE0099Medicare ID - Type Unspecified