=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346771953
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PHILLIP GRAY
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2017
-----------------------------------------------------
Last Update Date | 08/08/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 246 PLEASANT ST STE 205
-----------------------------------------------------
City | CONCORD
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03301-7546
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-224-0584
-----------------------------------------------------
Fax | 603-227-7560
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 246 PLEASANT ST STE 205
-----------------------------------------------------
City | CONCORD
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03301-2548
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-224-0584
-----------------------------------------------------
Fax | 603-227-7560
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 20256
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------