Provider Demographics
NPI:1386181212
Name:GREGORY, EDDIE III
Entity Type:Individual
Prefix:
First Name:EDDIE
Middle Name:
Last Name:GREGORY
Suffix:III
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 1:2615 BENJAMIN ST
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-5736
Mailing Address - Country:US
Mailing Address - Phone:989-522-2900
Mailing Address - Fax:
Practice Address - Street 1:2615 BENJAMIN ST
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-5736
Practice Address - Country:US
Practice Address - Phone:989-522-2900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-30
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIF08388374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide