Provider Demographics
NPI:1043391121
Name:GREY CANYON FAMILY MEDICINE PA
Entity Type:Organization
Organization Name:GREY CANYON FAMILY MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:MACGILLIVRAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-615-9990
Mailing Address - Street 1:20658 STONE OAK PKWY
Mailing Address - Street 2:STE 108
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258
Mailing Address - Country:US
Mailing Address - Phone:210-615-9990
Mailing Address - Fax:210-615-9909
Practice Address - Street 1:20658 STONE OAK PKWY
Practice Address - Street 2:STE 108
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258
Practice Address - Country:US
Practice Address - Phone:210-615-9990
Practice Address - Fax:210-615-9909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM3304207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX=========OtherEIN