Healthcare Provider Details

I. General information

NPI: 1134909575
Provider Name (Legal Business Name): GRAY REIGN MEDICAL, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2023
Last Update Date: 03/25/2024
Certification Date: 02/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6255 28TH STREET SE SUITE 2
GRAND RAPIDS MI
49546
US

IV. Provider business mailing address

6255 28TH STREET SE SUITE 2
GRAND RAPIDS MI
49546
US

V. Phone/Fax

Practice location:
  • Phone: 616-980-0901
  • Fax: 616-980-2231
Mailing address:
  • Phone: 616-980-0901
  • Fax: 616-980-2231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. AFRIYIE GRAY
Title or Position: OWNER
Credential: D.O
Phone: 616-980-0901