Healthcare Provider Details

I. General information

NPI: 1952592594
Provider Name (Legal Business Name): GARY GRAY PHYSICAL THERAPY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2007
Last Update Date: 02/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 W MAUMEE ST SUITE 125
ADRIAN MI
49221-1291
US

IV. Provider business mailing address

205 W WACKER DR SUITE 1020
CHICAGO IL
60606-1216
US

V. Phone/Fax

Practice location:
  • Phone: 517-264-6141
  • Fax: 517-263-5786
Mailing address:
  • Phone: 312-640-0329
  • Fax: 312-640-0407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateMI

VIII. Authorized Official

Name: RANDOLPH P FRIESER
Title or Position: PRESIDENT/SECRETARY
Credential: PT
Phone: 312-640-0329