Provider Demographics
NPI:1194899310
Name:GRECO, MARY ELLEN (MD)
Entity type:Individual
Prefix:
First Name:MARY ELLEN
Middle Name:
Last Name:GRECO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4900 BROAD RD
Mailing Address - Street 2:SUITE 1D
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13215-2265
Mailing Address - Country:US
Mailing Address - Phone:315-492-5660
Mailing Address - Fax:315-492-3571
Practice Address - Street 1:4900 BROAD RD
Practice Address - Street 2:SUITE 1D
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13215-2265
Practice Address - Country:US
Practice Address - Phone:315-492-5660
Practice Address - Fax:315-492-3571
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2038771208600000X, 2086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCC4129Medicaid
G35225Medicare UPIN
NYCC4129Medicaid