Healthcare Provider Details

I. General information

NPI: 1003504929
Provider Name (Legal Business Name): JOSHUA GRAY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2023
Last Update Date: 04/27/2023
Certification Date: 04/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

758 BROADWAY
BANGOR ME
04401-3224
US

IV. Provider business mailing address

324 MEDFORD RD
LAGRANGE ME
04453-5214
US

V. Phone/Fax

Practice location:
  • Phone: 207-941-8400
  • Fax:
Mailing address:
  • Phone: 207-943-6872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPT5951
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: