Provider Demographics
NPI:1871692798
Name:LINK, GREG (DO)
Entity type:Individual
Prefix:
First Name:GREG
Middle Name:
Last Name:LINK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3817 S SPRINGFIELD AVE
Mailing Address - Street 2:SUITE 140
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-9129
Mailing Address - Country:US
Mailing Address - Phone:417-422-4769
Mailing Address - Fax:
Practice Address - Street 1:3817 S SPRINGFIELD AVE
Practice Address - Street 2:SUITE 140
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-9129
Practice Address - Country:US
Practice Address - Phone:417-422-4769
Practice Address - Fax:309-284-2244
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-096023207Q00000X
MO2019036152207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036096023Medicaid
IL809840Other809840 GROUP FOR PEORIA
ILL71353Medicare ID - Type UnspecifiedINDIVIDUAL #
IL036096023Medicaid
G42253Medicare UPIN
IL833610Medicare ID - Type UnspecifiedGROUP #
IL809840Other809840 GROUP FOR PEORIA
IL080142761Medicare ID - Type UnspecifiedRR INDIVIDUAL #