Provider Demographics
NPI:1952592594
Name:GARY GRAY PHYSICAL THERAPY CLINIC
Entity Type:Organization
Organization Name:GARY GRAY PHYSICAL THERAPY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:RANDOLPH
Authorized Official - Middle Name:P
Authorized Official - Last Name:FRIESER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:312-640-0329
Mailing Address - Street 1:205 W WACKER DR
Mailing Address - Street 2:SUITE 1020
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60606-1216
Mailing Address - Country:US
Mailing Address - Phone:312-640-0329
Mailing Address - Fax:312-640-0407
Practice Address - Street 1:1801 W MAUMEE ST
Practice Address - Street 2:SUITE 125
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-1291
Practice Address - Country:US
Practice Address - Phone:517-264-6141
Practice Address - Fax:517-263-5786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-08
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI225100000X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI26-6636OtherMEDICARE ID