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General NPI Number Information
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NPI Number | 1376637132
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Entity Type | Individual
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Provider Name | BENNETT G GRAY IV MD
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Gender | Male
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Dates
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Enumeration Date | 10/03/2006
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Last Update Date | 05/13/2024
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Provider Practice Location Address
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Address Line | 9821 IRVINE CENTER DR
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City | IRVINE
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State | CA
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Zip | 92618-4307
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Country | US
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Telephone | 800-741-7629
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Fax |
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Provider Business Mailing Address
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Address Line | 77 E SOUTHCREST CIR
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City | EDWARDSVILLE
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State | IL
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Zip | 62025-3147
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Country | US
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Telephone | 618-659-0457
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 036067155
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License Number State | IL
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