Provider Demographics
NPI:1407854516
Name:BOONE, GREGORY (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:
Last Name:BOONE
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 1:1330 MERCY DR NW
Mailing Address - Street 2:SUITE 319
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708-2626
Mailing Address - Country:US
Mailing Address - Phone:330-580-4706
Mailing Address - Fax:330-580-4707
Practice Address - Street 1:1330 MERCY DR NW
Practice Address - Street 2:SUITE 319
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708-2626
Practice Address - Country:US
Practice Address - Phone:330-580-4706
Practice Address - Fax:330-580-4707
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35052710208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1700048OtherUNITED HEALTHCARE
OH000000600139OtherANTHEM BC/BS
OH0776665Medicaid
OH67552OtherFIRST HEALTH
OH2157366OtherGROUP MEDICAID
OH9303389OtherGROUP MEDICARE MPCC
OH0673737Medicare PIN
OH9303389OtherGROUP MEDICARE MPCC
OH67552OtherFIRST HEALTH