1336108612 NPI number — ANDREA B GRAY MS

Table of content: ANDREA B GRAY MS (NPI 1336108612)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336108612 NPI number — ANDREA B GRAY MS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAY
Provider First Name:
ANDREA
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BILLEY
Provider Other First Name:
ANDREA
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.S.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1336108612
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/02/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
823 PARK EAST BLVD STE H
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47905-0811
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-448-6226
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
823 PARK EAST BLVD STE H
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47905-0811
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-448-6226
Provider Business Practice Location Address Fax Number:
765-448-9416
Provider Enumeration Date:
03/23/2006

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: 231H00000X , with the licence number:  23002183A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000179545 . This is a "ANTHEM PROVIDER NUMBER" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200180390 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: HA57500064 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9397785 . This is a "PHCS PID NUMBER" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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