MEDICARE: MR. CHARLES RICHARD GRAY PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	2003002307	MO
2	363AM0700X	Medical Physician Assistant	PA.0002579	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	523191	OTHER	MO	HEALTHLINK
2	173190	OTHER	MO	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1316970163
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHARLES RICHARD GRAY PA

Provider Business Mailing Address
First Line	:	4790 FARTHING DRIVE
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906
Country	:	US
Telephone Number	:	719-963-7579
Fax Number	:	719-538-2961

Provider Business Practice Location Address
First Line	:	3207 N ACADEMY BLVD STE 3500
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80917-5100
Country	:	US
Telephone Number	:	719-632-5700
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2006
Last Update Date	:	07/12/2023

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