Provider Demographics
NPI:1083646152
Name:GRAY, SCOT M (DC)
Entity Type:Individual
Prefix:DR
First Name:SCOT
Middle Name:M
Last Name:GRAY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1448 MARION WALDO RD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-7422
Mailing Address - Country:US
Mailing Address - Phone:740-386-6580
Mailing Address - Fax:740-386-6586
Practice Address - Street 1:1448 MARION WALDO RD
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-7422
Practice Address - Country:US
Practice Address - Phone:740-386-6580
Practice Address - Fax:740-386-6586
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3465111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2484084Medicaid
OH000000334224OtherANTHEM
OHP00205158Medicare ID - Type UnspecifiedRAILROAD MEDICARE
OH2484084Medicaid
OHMA9345101Medicare ID - Type UnspecifiedMEDICARE