Provider Demographics
NPI:1205090735
Name:MARY ELLEN GRECO MD PC
Entity type:Organization
Organization Name:MARY ELLEN GRECO MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY ELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRECO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-470-7942
Mailing Address - Street 1:725 IRVING AVE
Mailing Address - Street 2:SUITE 314
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1603
Mailing Address - Country:US
Mailing Address - Phone:315-470-7942
Mailing Address - Fax:315-470-2722
Practice Address - Street 1:725 IRVING AVE
Practice Address - Street 2:SUITE 314
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1603
Practice Address - Country:US
Practice Address - Phone:315-470-7942
Practice Address - Fax:315-470-2722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-14
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY203877208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0168727Medicaid
NYCC4129Medicare PIN
NYG35225Medicare UPIN