Basic Information
| Provider Information | |||||||||
| NPI: | 1104982628 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREY | ||||||||
| FirstName: | EARLE | ||||||||
| MiddleName: | C. | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10744 | ||||||||
| Address2: | |||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337578744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275320002 | ||||||||
| FaxNumber: | 7272664928 | ||||||||
| Practice Location | |||||||||
| Address1: | 4726 N HABANA AVE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336147144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138794328 | ||||||||
| FaxNumber: | 8134438152 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2006 | ||||||||
| LastUpdateDate: | 01/21/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9108320 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 013890700 | 05 | FL | MEDICAID |