Provider Demographics
NPI:1528416088
Name:ELY, GREGORY (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:ELY
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 1:4756 E 10TH ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-3006
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:103 MEDICINE WAY RD
Practice Address - Street 2:
Practice Address - City:PERIDOT
Practice Address - State:AZ
Practice Address - Zip Code:85542-5000
Practice Address - Country:US
Practice Address - Phone:928-475-1400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-25
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ58573207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine