Provider Demographics
NPI:1497784797
Name:BULLIS, GREGORY (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:BULLIS
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 1:5666 EAST STATE ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2472
Mailing Address - Country:US
Mailing Address - Phone:815-226-2000
Mailing Address - Fax:815-381-7582
Practice Address - Street 1:5666 EAST STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2472
Practice Address - Country:US
Practice Address - Phone:815-226-2000
Practice Address - Fax:815-381-7582
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036067306207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36067306Medicaid
ILK05805Medicare ID - Type Unspecified
IL36067306Medicaid