1194960682 NPI number — DENNIS S. GRAY, M.D., PSC

Table of content: (NPI 1194960682)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194960682 NPI number — DENNIS S. GRAY, M.D., PSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DENNIS S. GRAY, M.D., PSC
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:
1194960682
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/10/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1169 EASTERN PKWY
Provider Second Line Business Mailing Address:
SUITE 1111
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40217-1417
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-456-4100
Provider Business Mailing Address Fax Number:
502-459-8454

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1169 EASTERN PKWY
Provider Second Line Business Practice Location Address:
SUITE 1111
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40217-1417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-456-4100
Provider Business Practice Location Address Fax Number:
502-459-8454
Provider Enumeration Date:
12/11/2008

Additional Information

Authorized Official

Authorized Official Last Name:
GRAY
Authorized Official First Name:
DENNIS
Authorized Official Middle Name:
S.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
502-456-4100

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 000000600890 . This is a "BC BS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 58216840 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3633465001 . This is a "PASSPORT ADVANTAGE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: DO3964 . This is a "RR MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 50021729 . This is a "PASSPORT" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 7100065390 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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