1659411494 NPI number — ROBERT W GRAY DPH

Table of content: ROBERT W GRAY DPH (NPI 1659411494)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659411494 NPI number — ROBERT W GRAY DPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAY
Provider First Name:
ROBERT
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPH
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659411494
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
45 S MECHANIC ST
Provider Second Line Business Mailing Address:
P.O. BOX 174
Provider Business Mailing Address City Name:
LYNCHBURG
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37352-8353
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
931-759-7329
Provider Business Mailing Address Fax Number:
931-759-4604

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
45 S MECHANIC ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LYNCHBURG
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37352-8353
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-759-7329
Provider Business Practice Location Address Fax Number:
931-759-4604
Provider Enumeration Date:
02/08/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  005858 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4424595 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4424595 . This is a "NCPDP" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 1454364 . This is a "TN MEDICAL ASSISTANCE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".