Provider Demographics
NPI:1285738690
Name:MELLOR, GREGORY
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:MELLOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 WASHINGTON ST
Mailing Address - Street 2:EIGHT TOWER BRIDGE, SUITE 1400
Mailing Address - City:CONSHOHOCKEN
Mailing Address - State:PA
Mailing Address - Zip Code:19428-2083
Mailing Address - Country:US
Mailing Address - Phone:866-825-3227
Mailing Address - Fax:484-351-3800
Practice Address - Street 1:6701 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63129
Practice Address - Country:US
Practice Address - Phone:866-825-3227
Practice Address - Fax:484-351-3800
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO097908363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOR76293Medicare UPIN