Provider Demographics
NPI:1083615934
Name:WHEATLEY, GRAYSON H III (MD)
Entity Type:Individual
Prefix:
First Name:GRAYSON
Middle Name:H
Last Name:WHEATLEY
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 PATTERSON ST
Mailing Address - Street 2:SUITE 307
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1562
Mailing Address - Country:US
Mailing Address - Phone:615-342-6900
Mailing Address - Fax:615-342-6899
Practice Address - Street 1:2400 PATTERSON ST
Practice Address - Street 2:SUITE 307
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-1562
Practice Address - Country:US
Practice Address - Phone:615-342-6900
Practice Address - Fax:615-342-6899
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ332172086S0129X
PAMD448565208600000X
TN54798208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP00219385OtherRAILROAD MEDICARE
TN54798OtherTN MEDICAL LICENSE
AZ891186Medicaid
AZWCSKQOtherSUN HEALTH GROUP #
AZWCSKQOtherSUN HEALTH GROUP #
AZI18735Medicare UPIN
AZZ107070Medicare PIN