Provider Demographics
NPI:1790778165
Name:GRAY, BRUCE CARSON (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:CARSON
Last Name:GRAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 20452
Mailing Address - Street 2:WOAA-CRED
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220-0452
Mailing Address - Country:US
Mailing Address - Phone:513-524-5574
Mailing Address - Fax:614-442-2410
Practice Address - Street 1:110 N POPLAR ST
Practice Address - Street 2:MCCULLOUGH HYDE MEM HOSP ANESTHESIA DEPT
Practice Address - City:OXFORD
Practice Address - State:OH
Practice Address - Zip Code:45056-1204
Practice Address - Country:US
Practice Address - Phone:513-524-5440
Practice Address - Fax:513-524-5559
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-31
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35082188207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0200306220Medicaid
OHP00096729OtherRAILROAD MEDICARE
OH2424102Medicaid
OH2424102Medicaid
OHG00664Medicare UPIN