Provider Demographics
NPI:1023066495
Name:GRAY, BRUCE HARVEY (DO)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:HARVEY
Last Name:GRAY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 PATEWOOD DR
Practice Address - Street 2:SUITE C300
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3557
Practice Address - Country:US
Practice Address - Phone:864-454-8272
Practice Address - Fax:864-454-2875
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC606207R00000X
SC06062086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC4466189OtherAETNA
SCT00237Medicaid
SC110218125OtherRR MEDICARE
SC576007863093OtherBLUE CHOICE OF SC
RI576007863071OtherBCBS OF SC
SC1864198OtherCIGNA
SCE764467951Medicare PIN
SC576007863093OtherBLUE CHOICE OF SC
RI576007863071OtherBCBS OF SC