Provider Demographics
NPI:1467051250
Name:GRAY, CHARLES M
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:M
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 1:5863 RENNINGER RD
Mailing Address - Street 2:
Mailing Address - City:NEW FRANKLIN
Mailing Address - State:OH
Mailing Address - Zip Code:44319
Mailing Address - Country:US
Mailing Address - Phone:330-212-8757
Mailing Address - Fax:
Practice Address - Street 1:5863 RENNINGER ROAD
Practice Address - Street 2:
Practice Address - City:NEW FRANKLIN
Practice Address - State:OH
Practice Address - Zip Code:44319
Practice Address - Country:US
Practice Address - Phone:330-212-8757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-22
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH343900000X, 3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH7716529Medicaid