Basic Information
Provider Information | |||||||||
NPI: | 1902836679 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BRAY | ||||||||
FirstName: | GREGORY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1 SAINT ELIZABETH BLVD | ||||||||
Address2: |   | ||||||||
City: | O FALLON | ||||||||
State: | IL | ||||||||
PostalCode: | 622691099 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6182342120 | ||||||||
FaxNumber: | 6185415810 | ||||||||
Practice Location | |||||||||
Address1: | 1 SAINT ELIZABETH BLVD | ||||||||
Address2: |   | ||||||||
City: | O FALLON | ||||||||
State: | IL | ||||||||
PostalCode: | 622691099 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6182342120 | ||||||||
FaxNumber: | 6185415810 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/05/2006 | ||||||||
LastUpdateDate: | 01/10/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/10/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 01046469A | IN | N |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 207L00000X | 036151250 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | 000000598514 | 01 | IN | ANTHEM | OTHER | 200144250 | 05 | IN |   | MEDICAID |