Provider Demographics
NPI:1922178094
Name:GLEN GRAYMAN, M.D., INC.
Entity Type:Organization
Organization Name:GLEN GRAYMAN, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAYMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-954-4030
Mailing Address - Street 1:35012 MISSION HILLS DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-1305
Mailing Address - Country:US
Mailing Address - Phone:760-954-4030
Mailing Address - Fax:760-406-5611
Practice Address - Street 1:35012 MISSION HILLS DR
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-1305
Practice Address - Country:US
Practice Address - Phone:760-954-4030
Practice Address - Fax:760-406-5611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG29724207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA44131Medicare UPIN