1710289343 NPI number — ROBERT BENJAMIN GRAY DPT

Table of content: ROBERT BENJAMIN GRAY DPT (NPI 1710289343)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710289343 NPI number — ROBERT BENJAMIN GRAY DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAY
Provider First Name:
ROBERT
Provider Middle Name:
BENJAMIN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
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:
1710289343
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/22/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4 OFFICE PARK CIR
Provider Second Line Business Mailing Address:
SUITE 217
Provider Business Mailing Address City Name:
MOUNTAIN BRK
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35223-2511
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-263-2770
Provider Business Mailing Address Fax Number:
205-263-0994

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2808 7TH AVE S
Provider Second Line Business Practice Location Address:
SUITE 111
Provider Business Practice Location Address City Name:
BIRMINGHAM
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35233-2813
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-745-3976
Provider Business Practice Location Address Fax Number:
205-453-4221
Provider Enumeration Date:
12/02/2010

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: 225100000X , with the licence number:  PTH6019 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PTH6019 . This is a "STATE LICENSE NUMBER" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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