Provider Demographics
NPI:1174999106
Name:SMALL, GARY
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:SMALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 W STURBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-3889
Mailing Address - Country:US
Mailing Address - Phone:330-783-5334
Mailing Address - Fax:
Practice Address - Street 1:285 W STURBRIDGE DR
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-3889
Practice Address - Country:US
Practice Address - Phone:330-783-5334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-13
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH525135343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0141850Medicaid