Provider Demographics
NPI:1376754309
Name:GREGORY P. COLLIS
Entity Type:Organization
Organization Name:GREGORY P. COLLIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:COLLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-382-6725
Mailing Address - Street 1:212 HIGHLAND ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203-1603
Mailing Address - Country:US
Mailing Address - Phone:315-382-6725
Mailing Address - Fax:
Practice Address - Street 1:8196 GREEN RD
Practice Address - Street 2:
Practice Address - City:HUBBARDSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13355-1132
Practice Address - Country:US
Practice Address - Phone:315-382-6725
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY02056302343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02056302Medicaid