Provider Demographics
NPI:1114169299
Name:W. WILSON GRAY JR., M.D.PHD.P.C.
Entity Type:Organization
Organization Name:W. WILSON GRAY JR., M.D.PHD.P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:WOODROW
Authorized Official - Middle Name:WILSON
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD,PHD
Authorized Official - Phone:478-742-0059
Mailing Address - Street 1:840 PINE ST
Mailing Address - Street 2:SUITE 910
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-2100
Mailing Address - Country:US
Mailing Address - Phone:478-742-0059
Mailing Address - Fax:478-746-3086
Practice Address - Street 1:840 PINE ST
Practice Address - Street 2:SUITE 910
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2100
Practice Address - Country:US
Practice Address - Phone:478-742-0059
Practice Address - Fax:478-746-3086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-03
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00292938CMedicaid
GA00292938CMedicaid