Provider Demographics
NPI:1861848004
Name:MUNDIE, GREGORY
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:
Last Name:MUNDIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18010 SILVER PKWY
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-3421
Mailing Address - Country:US
Mailing Address - Phone:810-750-2626
Mailing Address - Fax:
Practice Address - Street 1:18010 SILVER PKWY
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-3421
Practice Address - Country:US
Practice Address - Phone:810-750-2626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-06
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3501004431237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist