Basic Information
| Provider Information | |||||||||
| NPI: | 1194755181 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MYERS | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | JAY | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 480 HOPKINSVILLE STREET | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423451124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2703385777 | ||||||||
| FaxNumber: | 2703385765 | ||||||||
| Practice Location | |||||||||
| Address1: | 10220 DIXIE BEELINE HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | GUTHRIE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 422349310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2702200340 | ||||||||
| FaxNumber: | 2702200341 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 03/21/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 30319 | AL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 7100451250 | 05 | KY | MEDICAID | 611268014 | 01 | KY | FEDERAL TAX ID# | OTHER |