Provider Demographics
NPI:1316922214
Name:GRGURICH, MELANIE S (DO)
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:S
Last Name:GRGURICH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MELANIE
Other - Middle Name:S
Other - Last Name:HILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1416 CROWN DR
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-2548
Mailing Address - Country:US
Mailing Address - Phone:660-627-5757
Mailing Address - Fax:660-627-5802
Practice Address - Street 1:1506 CROWN DR
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-2553
Practice Address - Country:US
Practice Address - Phone:660-627-4493
Practice Address - Fax:660-627-4288
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO111208207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO244638110Medicaid
MO17400013Medicare PIN
MOG90953Medicare UPIN