Healthcare Provider Details

I. General information

NPI: 1912596081
Provider Name (Legal Business Name): ANTHONY J WRAY RRA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2021
Last Update Date: 01/13/2021
Certification Date: 01/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

714 N SENATE AVE STE 100
INDIANAPOLIS IN
46202-3297
US

IV. Provider business mailing address

714 N SENATE AVE STE 100
INDIANAPOLIS IN
46202-3297
US

V. Phone/Fax

Practice location:
  • Phone: 317-963-0156
  • Fax: 317-963-2711
Mailing address:
  • Phone: 317-963-0156
  • Fax: 317-963-2711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License NumberXT021684
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: