Healthcare Provider Details

I. General information

NPI: 1336120575
Provider Name (Legal Business Name): CHARLES P BRAY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 03/20/2024
Certification Date: 03/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2680 LEONARD ST NE STE 3
GRAND RAPIDS MI
49525-6901
US

IV. Provider business mailing address

5555 GLENWOOD HILLS PKWY SE STE 2
GRAND RAPIDS MI
49512-2091
US

V. Phone/Fax

Practice location:
  • Phone: 616-317-7246
  • Fax: 616-920-6540
Mailing address:
  • Phone: 616-940-2662
  • Fax: 616-940-1965

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601001995
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: