Basic Information
| Provider Information | |||||||||
| NPI: | 1659959633 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAY | ||||||||
| FirstName: | GANNON | ||||||||
| MiddleName: | JAMES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2451 UNIVERSITY HOSPITAL DR RM 714 | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366172300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514343915 | ||||||||
| FaxNumber: | 2514151387 | ||||||||
| Practice Location | |||||||||
| Address1: | 2451 UNIVERSITY HOSPITAL DR RM 714 | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366172300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514343915 | ||||||||
| FaxNumber: | 2514151387 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2021 | ||||||||
| LastUpdateDate: | 03/31/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | AL | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.