Provider Demographics
NPI:1750807558
Name:DALE GRAY M.D.,S.C.
Entity type:Organization
Organization Name:DALE GRAY M.D.,S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-962-0633
Mailing Address - Street 1:2720 GLENWOOD CT
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61101-3507
Mailing Address - Country:US
Mailing Address - Phone:815-962-0633
Mailing Address - Fax:
Practice Address - Street 1:2720 GLENWOOD CT
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61101-3507
Practice Address - Country:US
Practice Address - Phone:815-962-0633
Practice Address - Fax:815-962-0142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-14
Last Update Date:2017-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036072289261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care