Provider Demographics
NPI:1962681502
Name:DONALD KEVIN GREGORY MD, PSC
Entity Type:Organization
Organization Name:DONALD KEVIN GREGORY MD, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:GAIL
Authorized Official - Last Name:GREGORY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-274-4771
Mailing Address - Street 1:1213 NORTH MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:KY
Mailing Address - Zip Code:42320-0308
Mailing Address - Country:US
Mailing Address - Phone:270-274-4771
Mailing Address - Fax:270-274-4884
Practice Address - Street 1:1213 N MAIN ST.
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:KY
Practice Address - Zip Code:42320-0308
Practice Address - Country:US
Practice Address - Phone:270-274-4771
Practice Address - Fax:270-274-4884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-31
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY298623207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY298623OtherLICENSE
000000528018OtherANTHEM
11750443OtherCAQH
KY64298623Medicaid
000000528018OtherANTHEM