Provider Demographics
NPI:1114286945
Name:FAITH M. GRAY, M.D., INC.
Entity Type:Organization
Organization Name:FAITH M. GRAY, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:FAITH
Authorized Official - Middle Name:M
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-806-8710
Mailing Address - Street 1:PO BOX 308
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30048-0308
Mailing Address - Country:US
Mailing Address - Phone:770-806-8710
Mailing Address - Fax:770-806-0564
Practice Address - Street 1:3993 LAWRENCEVILLE HWY NW
Practice Address - Street 2:SUITE 115
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-2897
Practice Address - Country:US
Practice Address - Phone:770-806-8710
Practice Address - Fax:770-806-0564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-14
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA036165261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
F73257Medicare UPIN