Basic Information
| Provider Information | |||||||||
| NPI: | 1023066495 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAY | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | HARVEY | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 E MCBEE AVE FL 4 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296012842 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 PATEWOOD DR | ||||||||
| Address2: | SUITE C300 | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296153557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644548272 | ||||||||
| FaxNumber: | 8644542875 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 10/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 606 | SC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 2086S0129X | 0606 | SC | N | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 4466189 | 01 | SC | AETNA | OTHER | T00237 | 05 | SC | MEDICAID | 110218125 | 01 | SC | RR MEDICARE | OTHER | 576007863093 | 01 | SC | BLUE CHOICE OF SC | OTHER | 576007863071 | 01 | RI | BCBS OF SC | OTHER | 1864198 | 01 | SC | CIGNA | OTHER |