Provider Demographics
NPI:1992834535
Name:GRAY, SAMUEL ADAM (DC)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:ADAM
Last Name:GRAY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 ELIZABETH LAKE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328
Mailing Address - Country:US
Mailing Address - Phone:248-683-6260
Mailing Address - Fax:248-683-0256
Practice Address - Street 1:2801 ELIZABETH LAKE ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328
Practice Address - Country:US
Practice Address - Phone:248-683-6260
Practice Address - Fax:248-683-0256
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301006572111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OF35264Medicare ID - Type Unspecified
T33426Medicare UPIN
MI5951Medicare PIN