Provider Demographics
NPI:1891890794
Name:DR. PHILLIP H. GRAY, P.A.
Entity Type:Organization
Organization Name:DR. PHILLIP H. GRAY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:H
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-423-3785
Mailing Address - Street 1:105 S FULTON ST
Mailing Address - Street 2:
Mailing Address - City:IUKA
Mailing Address - State:MS
Mailing Address - Zip Code:38852-2328
Mailing Address - Country:US
Mailing Address - Phone:662-423-3785
Mailing Address - Fax:
Practice Address - Street 1:105 S FULTON ST
Practice Address - Street 2:
Practice Address - City:IUKA
Practice Address - State:MS
Practice Address - Zip Code:38852-2328
Practice Address - Country:US
Practice Address - Phone:662-423-3785
Practice Address - Fax:662-423-2849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS94020152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00087882Medicaid
MS560945932Medicare ID - Type Unspecified
MS0128070001Medicare NSC
MS00087882Medicaid