Provider Demographics
NPI:1497020846
Name:RIVES GRAY, TYLER (MD)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:RIVES GRAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 W BALTIMORE ST
Mailing Address - Street 2:SUITE 247
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21223-1558
Mailing Address - Country:US
Mailing Address - Phone:443-703-1400
Mailing Address - Fax:443-703-1499
Practice Address - Street 1:2000 W BALTIMORE ST
Practice Address - Street 2:SUITE 247
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21223-1558
Practice Address - Country:US
Practice Address - Phone:443-703-1400
Practice Address - Fax:443-703-1499
Is Sole Proprietor?:No
Enumeration Date:2012-03-19
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD80230207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD383841200Medicaid