Provider Demographics
NPI:1184746281
Name:GERARDO A. GRIECO, M.D., S.C.
Entity type:Organization
Organization Name:GERARDO A. GRIECO, M.D., S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TAYLOR
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIECO
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:309-452-1193
Mailing Address - Street 1:1300 FRANKLIN AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-3592
Mailing Address - Country:US
Mailing Address - Phone:309-452-1193
Mailing Address - Fax:309-452-1349
Practice Address - Street 1:1300 FRANKLIN AVE STE 210
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-3588
Practice Address - Country:US
Practice Address - Phone:309-452-1193
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL05715632OtherBCBS GROUP ID
ILDB8294OtherRR MEDICARE GROUP ID
ILDB8294OtherRR MEDICARE GROUP ID