Provider Demographics
NPI:1891878005
Name:GRAY, JERMAINE E (MD)
Entity Type:Individual
Prefix:
First Name:JERMAINE
Middle Name:E
Last Name: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 1:500 UNIVERSITY DRIVE
Mailing Address - Street 2:
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-2360
Mailing Address - Country:US
Mailing Address - Phone:800-243-1455
Mailing Address - Fax:
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5373
Practice Address - Fax:601-984-5476
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD473875207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04358321Medicaid
MS160000807OtherMEDICARE PROV #
MS512I160025OtherMEDICARE PTAN#
MS512G700003OtherUP MEDICARE GRP PROV#
MS08103071OtherUP MEDICAID GROUP PROV#
MS302I167019Medicare PIN
MS04358321Medicaid
MS512G700003OtherUP MEDICARE GRP PROV#
MS512I160025OtherMEDICARE PTAN#
MSI48816Medicare UPIN