Provider Demographics
NPI:1902179914
Name:GARY GREGERSON MD PA
Entity Type:Organization
Organization Name:GARY GREGERSON MD PA
Other - Org Name:ADVANCED SPECIALTY CARE FOR WOMEN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:N
Authorized Official - Last Name:GREGERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-468-9400
Mailing Address - Street 1:1611 12TH AVE ROAD
Mailing Address - Street 2:SUITE A
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-6182
Mailing Address - Country:US
Mailing Address - Phone:208-468-9400
Mailing Address - Fax:208-468-9447
Practice Address - Street 1:1611 12TH AVE ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-6182
Practice Address - Country:US
Practice Address - Phone:208-468-9400
Practice Address - Fax:208-468-9447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-22
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-6312207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty