Provider Demographics
NPI:1427187061
Name:SAMUEL A GRAY DC
Entity Type:Organization
Organization Name:SAMUEL A GRAY DC
Other - Org Name:SUMMIT CHIROPRACTIC PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:ADAM
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:248-683-6260
Mailing Address - Street 1:2801 ELIZABETH LAKE ROAD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328
Mailing Address - Country:US
Mailing Address - Phone:248-683-6260
Mailing Address - Fax:248-683-0256
Practice Address - Street 1:2801 ELIZABETH LAKE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328
Practice Address - Country:US
Practice Address - Phone:248-683-6260
Practice Address - Fax:248-683-0256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301006572111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI=========OtherPPOM
OF35264Medicare ID - Type Unspecified
5951Medicare ID - Type Unspecified
MI=========OtherPPOM