Provider Demographics
NPI:1710002001
Name:KRISTYN GREGORY DO PC
Entity Type:Organization
Organization Name:KRISTYN GREGORY DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTYN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:GREGORY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:586-203-2020
Mailing Address - Street 1:16075 WHITE WATER DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48042-6183
Mailing Address - Country:US
Mailing Address - Phone:810-794-7750
Mailing Address - Fax:810-794-7751
Practice Address - Street 1:57327 VAN DYKE RD
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MI
Practice Address - Zip Code:48094-2892
Practice Address - Country:US
Practice Address - Phone:586-203-2020
Practice Address - Fax:586-992-1210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010145612084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2655012874OtherBCBSM
MI=========OtherTAX ID