MEDICARE: MR. ROBERT SIMPSON GRAY JR. ATC

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	2255A2300X	Athletic Trainer	AT000284	OH

General Provider Information

NPI Number	:	1972532455
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROBERT SIMPSON GRAY JR. ATC

Provider Business Mailing Address
First Line	:	126 PEPPERDINE DR
Second Line	:
City	:	ELYRIA
State	:	OH
Zip	:	44035-1566
Country	:	US
Telephone Number	:	440-366-9429
Fax Number	:	440-899-3160

Provider Business Practice Location Address
First Line	:	30033 CLEMENS RD
Second Line	:
City	:	WESTLAKE
State	:	OH
Zip	:	44145-1021
Country	:	US
Telephone Number	:	440-899-5645
Fax Number	:	440-899-3160

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

Provider Enumeration Date	:	06/30/2006
Last Update Date	:	07/08/2007

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