Provider Demographics
NPI:1407095805
Name:GARY M MCCRAY MD SC
Entity Type:Organization
Organization Name:GARY M MCCRAY MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:MYLES
Authorized Official - Last Name:MCCRAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-783-5572
Mailing Address - Street 1:1530 ALIMA TER
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60526-1331
Mailing Address - Country:US
Mailing Address - Phone:708-783-5572
Mailing Address - Fax:708-482-4093
Practice Address - Street 1:1530 ALIMA TER
Practice Address - Street 2:
Practice Address - City:LA GRANGE PARK
Practice Address - State:IL
Practice Address - Zip Code:60526-1331
Practice Address - Country:US
Practice Address - Phone:708-783-5572
Practice Address - Fax:708-482-4093
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GARY M MCCRAY MD SC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-02-10
Last Update Date:2009-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036064789207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036064789Medicaid
IL01621773OtherBLUE SHEILD
IL1023025541OtherTYPE I NPI
IL1255512976OtherTYPE II NPI
IL1023025541OtherTYPE I NPI
ILC37113Medicare UPIN
IL211557Medicare PIN