Provider Demographics
NPI:1619069507
Name:GRAY, THOMAS (CRNA)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:GRAY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 HEALTH CENTER DRIVE
Mailing Address - Street 2:ANESTHESIOLOGY DEPARTMENT
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938
Mailing Address - Country:US
Mailing Address - Phone:217-258-2440
Mailing Address - Fax:
Practice Address - Street 1:1000 HEALTH CENTER DRIVE
Practice Address - Street 2:ANESTHESIOLOGY DEPARTMENT
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938
Practice Address - Country:US
Practice Address - Phone:217-258-2440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-000882367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL86913Medicare PIN