Provider Demographics
NPI:1578902664
Name:GRAY, TED ALLEN
Entity Type:Individual
Prefix:
First Name:TED
Middle Name:ALLEN
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:PO BOX 157
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:IN
Mailing Address - Zip Code:46917-0157
Mailing Address - Country:US
Mailing Address - Phone:765-202-2634
Mailing Address - Fax:
Practice Address - Street 1:250 N WATER ST
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:IN
Practice Address - Zip Code:46917-9159
Practice Address - Country:US
Practice Address - Phone:765-202-2634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-21
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle