Provider Demographics
NPI:1548481716
Name:GREGORY, MEDINA H (DO)
Entity type:Individual
Prefix:
First Name:MEDINA
Middle Name:H
Last Name:GREGORY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MEDINA
Other - Middle Name:H
Other - Last Name:SHALTRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:825 N CENTER AVE
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-1592
Mailing Address - Country:US
Mailing Address - Phone:989-731-2100
Mailing Address - Fax:989-731-2205
Practice Address - Street 1:825 N CENTER AVE
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-1592
Practice Address - Country:US
Practice Address - Phone:989-731-2100
Practice Address - Fax:989-731-2205
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101015366207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0556910245OtherBLUE SHIELD
MI5179054Medicaid
MI0M10800005Medicare PIN