Healthcare Provider Details

I. General information

NPI: 1447332895
Provider Name (Legal Business Name): SCHARAZARD LEE GRAY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 02/02/2022
Certification Date: 02/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

523 3RD AVE
INTERNATIONAL FALLS MN
56649-2421
US

IV. Provider business mailing address

3039 COUNTY ROAD 127
INTERNATIONAL FALLS MN
56649-8724
US

V. Phone/Fax

Practice location:
  • Phone: 813-310-9346
  • Fax: 888-972-4098
Mailing address:
  • Phone: 813-310-9346
  • Fax: 888-972-4098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberMD-427277
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number122450
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number7910
License Number StateSD
# 4
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number65022
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: