Provider Demographics
NPI:1376637132
Name:GRAY, BENNETT (MD)
Entity Type:Individual
Prefix:DR
First Name:BENNETT
Middle Name:
Last Name:GRAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 E SOUTHCREST CIR
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-3147
Mailing Address - Country:US
Mailing Address - Phone:618-659-0457
Mailing Address - Fax:
Practice Address - Street 1:77 E SOUTHCREST CIR
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-3147
Practice Address - Country:US
Practice Address - Phone:618-659-0457
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04307022085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200364700AMedicaid
KSA29129Medicare UPIN
KS200364700AMedicaid