Healthcare Provider Details

I. General information

NPI: 1316033871
Provider Name (Legal Business Name): MICHAEL J. GRAY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 10/29/2021
Certification Date: 10/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 SOUTH ST
SOUTHBRIDGE MA
01550-4051
US

IV. Provider business mailing address

100 SOUTH ST
SOUTHBRIDGE MA
01550-4051
US

V. Phone/Fax

Practice location:
  • Phone: 508-765-9771
  • Fax: 508-764-2448
Mailing address:
  • Phone: 508-765-9771
  • Fax: 508-764-2448

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1553
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number246753
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: