Provider Demographics
NPI:1902836679
Name:BRAY, GREGORY (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:BRAY
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 1:1 SAINT ELIZABETH BLVD
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1099
Mailing Address - Country:US
Mailing Address - Phone:618-234-2120
Mailing Address - Fax:618-541-5810
Practice Address - Street 1:1 SAINT ELIZABETH BLVD
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1099
Practice Address - Country:US
Practice Address - Phone:618-234-2120
Practice Address - Fax:618-541-5810
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01046469A207L00000X
IL036151250207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000598514OtherANTHEM
IN200144250Medicaid
IN200144250Medicaid
IN000000598514OtherANTHEM
IN168040KKMedicare PIN