1487648945 NPI number — DR. ROBERT E WRAY DO

Table of content: DR. ROBERT E WRAY DO (NPI 1487648945)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487648945 NPI number — DR. ROBERT E WRAY DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WRAY
Provider First Name:
ROBERT
Provider Middle Name:
E
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1487648945
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/22/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
711 MARSH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KINSLEY
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67547-1129
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
620-659-2890
Provider Business Mailing Address Fax Number:
620-659-2897

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
810 W BRAMLEY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JETMORE
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67854-9320
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-357-8354
Provider Business Practice Location Address Fax Number:
620-357-6460
Provider Enumeration Date:
09/09/2005

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: 207QG0300X , with the licence number:  05-22793 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100230630E , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".




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