Healthcare Provider Details

I. General information

NPI: 1750321907
Provider Name (Legal Business Name): JOANNE T RAY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 01/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 JACKSON ST SUITE 204
ANDERSON IN
46016-4388
US

IV. Provider business mailing address

2101 JACKSON ST SUITE 204
ANDERSON IN
46016-4388
US

V. Phone/Fax

Practice location:
  • Phone: 765-642-8025
  • Fax: 765-642-8623
Mailing address:
  • Phone: 765-642-8025
  • Fax: 765-642-8623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01027454A
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier100170720A
Identifier TypeMEDICAID
Identifier StateIN
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: