Provider Demographics
NPI:1386839413
Name:JOHN H GRAY DO INC
Entity Type:Organization
Organization Name:JOHN H GRAY DO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:H
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:440-960-7474
Mailing Address - Street 1:3600 KOLBE RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44053-1654
Mailing Address - Country:US
Mailing Address - Phone:440-960-7474
Mailing Address - Fax:440-960-0225
Practice Address - Street 1:3600 KOLBE RD
Practice Address - Street 2:SUITE 210
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-1654
Practice Address - Country:US
Practice Address - Phone:440-960-7474
Practice Address - Fax:440-960-0225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-11
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34003191207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0507286Medicaid
OH9247311Medicare PIN
OH0507286Medicaid
OH0495894Medicare PIN