Provider Demographics
NPI:1770654089
Name:COLLINS, GREGORY (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:COLLINS
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 1:1836 LACKLAND HILL PKWY
Mailing Address - Street 2:CREDENTIALING DEPARTMENT
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-3572
Mailing Address - Country:US
Mailing Address - Phone:314-989-0300
Mailing Address - Fax:314-810-1399
Practice Address - Street 1:6810 STATE ROUTE 162
Practice Address - Street 2:STE 215
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-8501
Practice Address - Country:US
Practice Address - Phone:618-288-5711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036079652207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036079652002Medicaid
ILK11630Medicare PIN