Basic Information
| Provider Information | |||||||||
| NPI: | 1972703056 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMS GRAY | ||||||||
| FirstName: | AKEMIE | ||||||||
| MiddleName: | EDNA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WILLIAMS | ||||||||
| OtherFirstName: | AKEMIE | ||||||||
| OtherMiddleName: | EDNA | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 100 N 8TH ST STE 232 | ||||||||
| Address2: | |||||||||
| City: | EAST SAINT LOUIS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622012989 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183372597 | ||||||||
| FaxNumber: | 6183372930 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 N 8TH ST STE 232 | ||||||||
| Address2: | |||||||||
| City: | EAST SAINT LOUIS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622012989 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183372597 | ||||||||
| FaxNumber: | 6183372930 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2007 | ||||||||
| LastUpdateDate: | 03/22/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD60107061 | WA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 036131750 | IL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 8552374 | 05 | WA | MEDICAID |