Provider Demographics
NPI:1063476547
Name:GREGORY, RICHARD S (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:S
Last Name:GREGORY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-5000
Mailing Address - Fax:
Practice Address - Street 1:225 SMITH AVE N
Practice Address - Street 2:SUITE 200
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2533
Practice Address - Country:US
Practice Address - Phone:651-241-6550
Practice Address - Fax:651-241-6586
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN18727208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN18727OtherMN MEDICAL LICENSE
MN278588900Medicaid
MN18727OtherMN MEDICAL LICENSE
MN278588900Medicaid