Provider Demographics
NPI:1558372086
Name:HEALEY, GREGORY (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:HEALEY
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 1:25 PARK ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:NY
Mailing Address - Zip Code:13617-1265
Mailing Address - Country:US
Mailing Address - Phone:315-379-9158
Mailing Address - Fax:315-379-9604
Practice Address - Street 1:25 PARK ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617-1265
Practice Address - Country:US
Practice Address - Phone:315-379-9158
Practice Address - Fax:315-379-9604
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY214981-1207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01944370Medicaid
NYBB4909Medicare PIN
NYRB7888Medicare PIN
NY01944370Medicaid