Basic Information
Provider Information
NPI: 1003153180
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: GREGG
FirstName: JARED
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: CRNA
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 10005
Address2:  
City: FLORENCE
State: AL
PostalCode: 356312005
CountryCode: US
TelephoneNumber: 2567689191
FaxNumber: 2567689775
Practice Location
Address1: 205 MARENGO ST
Address2:  
City: FLORENCE
State: AL
PostalCode: 356306033
CountryCode: US
TelephoneNumber: 2567689191
FaxNumber: 2567689775
Other Information
ProviderEnumerationDate: 01/10/2013
LastUpdateDate: 04/17/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
367500000X1-167508ALY Physician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered 
367500000X4704294701MIN Physician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered 

ID Information
IDTypeStateIssuerDescription
470429470101MIMICHIGAN LICENSEOTHER


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