Provider Demographics
NPI:1629156914
Name:GREGORY, RODRICK R (MD PC)
Entity Type:Individual
Prefix:MR
First Name:RODRICK
Middle Name:R
Last Name:GREGORY
Suffix:
Gender:M
Credentials:MD PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 270
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:TN
Mailing Address - Zip Code:38478
Mailing Address - Country:US
Mailing Address - Phone:931-363-1414
Mailing Address - Fax:931-363-5743
Practice Address - Street 1:170 LOCKER ROAD
Practice Address - Street 2:
Practice Address - City:PULASKI
Practice Address - State:TN
Practice Address - Zip Code:38478
Practice Address - Country:US
Practice Address - Phone:931-363-1414
Practice Address - Fax:931-363-5743
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD319442084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
E79475Medicare UPIN
TN3844601Medicare ID - Type Unspecified