1821106105 NPI number — GRAY FAMILY VISION CENTER, P.A.

Table of content: (NPI 1821106105)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821106105 NPI number — GRAY FAMILY VISION CENTER, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRAY FAMILY VISION CENTER, P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1821106105
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/08/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1088
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAY
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04039-1088
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-657-4488
Provider Business Mailing Address Fax Number:
207-657-4574

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6 TURNPIKE ACRES ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAY
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04039
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-657-4488
Provider Business Practice Location Address Fax Number:
207-657-4574
Provider Enumeration Date:
08/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GUISELEY
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
207-657-4488

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OPT742 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: U59458 . This is a "COOK MEDICARE UPIN" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 000912 . This is a "GUISELEY ANTHEM #" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 005507769 . This is a "GUISELEY SS#" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 066629534 . This is a "COOK SS#" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 100225 . This is a "COOK ANTHEM" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 1194714733 . This is a "COOK IND NPI" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: MM9058 . This is a "COOK IND MEDICARE #" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 1558378737 . This is a "IND NPI FOR GUISELEY" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 161630000 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: T31390 . This is a "GUISELEY IND UPIN #" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".




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