Provider Demographics
NPI:1477761195
Name:GRAY, JERRY MCNICOLL (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:MCNICOLL
Last Name:GRAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:145 COLUMBIA AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-2987
Mailing Address - Country:US
Mailing Address - Phone:734-255-3884
Mailing Address - Fax:734-971-7079
Practice Address - Street 1:145 COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-2987
Practice Address - Country:US
Practice Address - Phone:734-255-3884
Practice Address - Fax:734-971-7079
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301023740207ZH0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301023740OtherPHYSICIAN LICENSE