Provider Demographics
NPI:1891340543
Name:GREGORY, BRAD JAMES
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:JAMES
Last Name:GREGORY
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 1:495 DEEPLANDS RD
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-2703
Mailing Address - Country:US
Mailing Address - Phone:313-590-6163
Mailing Address - Fax:
Practice Address - Street 1:495 DEEPLANDS RD
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE WOODS
Practice Address - State:MI
Practice Address - Zip Code:48236-2703
Practice Address - Country:US
Practice Address - Phone:313-590-6163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-08
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist