Provider Demographics
NPI:1134177058
Name:GREGORY, DANE (MD)
Entity type:Individual
Prefix:DR
First Name:DANE
Middle Name:
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 1:320 DOUBLE TREE DR SE
Mailing Address - Street 2:
Mailing Address - City:CALHOUN
Mailing Address - State:GA
Mailing Address - Zip Code:30701-4665
Mailing Address - Country:US
Mailing Address - Phone:706-602-9771
Mailing Address - Fax:
Practice Address - Street 1:320 DOUBLE TREE DR SE
Practice Address - Street 2:
Practice Address - City:CALHOUN
Practice Address - State:GA
Practice Address - Zip Code:30701-4665
Practice Address - Country:US
Practice Address - Phone:706-602-9771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050884207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA121044531AMedicaid
GA417905286OtherTRICARE
GA000941366LMedicaid
GA121044531AMedicaid