Provider Demographics
NPI:1346771953
Name:GRAY, PHILLIP
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:GRAY
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 1:246 PLEASANT ST STE 205
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301-2548
Mailing Address - Country:US
Mailing Address - Phone:603-224-0584
Mailing Address - Fax:603-227-7560
Practice Address - Street 1:246 PLEASANT ST STE 205
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-7546
Practice Address - Country:US
Practice Address - Phone:603-224-0584
Practice Address - Fax:603-227-7560
Is Sole Proprietor?:No
Enumeration Date:2017-03-24
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NH20256208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program