Provider Demographics
NPI:1568575595
Name:GREGG, GREGORY A (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:A
Last Name:GREGG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:611 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-5327
Mailing Address - Country:US
Mailing Address - Phone:217-544-2149
Mailing Address - Fax:217-544-9553
Practice Address - Street 1:800 E CARPENTER ST
Practice Address - Street 2:DEPARTMENT OF RADIOLOGY
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-5324
Practice Address - Country:US
Practice Address - Phone:217-544-6464
Practice Address - Fax:217-525-5671
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360642942085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL300026227OtherRR MEDICARE
ILP00028349OtherRR MEDICARE
IL36064294Medicaid
ILP00028349OtherRR MEDICARE
ILL73427Medicare PIN