Basic Information
| Provider Information | |||||||||
| NPI: | 1184651366 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WARREN | ||||||||
| FirstName: | GREGG | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26901 BEAUMONT BLVD STE 3D | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480333849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9475221865 | ||||||||
| FaxNumber: | 9475220307 | ||||||||
| Practice Location | |||||||||
| Address1: | 44201 DEQUINDRE RD | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480851117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2489645190 | ||||||||
| FaxNumber: | 2489645199 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 5101011119 | MI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 174400000X | 5101011119 | MI | N | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 1184651366 | 05 | MI | MEDICAID | 700F314390 | 01 | MI | BLUE SHIELD | OTHER | 700F281060 | 01 | MI | BLUE CARE NETWORK | OTHER |