Gray Derm LLC – Dermatology Physician, NPI 1104392679
Dermatology Physician
Main info
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Profile Insights
NPPES metrics only — not quality of care.
Provider Addresses for Gray Derm LLC
1005 Bellefontaine Ave Ste 300
Lima, OH 458042881
Phone: (419) 998-8297
Fax: (419) 226-8309
Type: Location
609 E Chestnut St
Lancaster, OH 431303900
Phone: (740) 206-7131
Type: Location
525 N EASTOWN RD STE A
LIMA, OH 458072268
Phone: (419) 998-8297
Fax: (419) 226-8309
Type: Location
1272, Hunter Avenue, Victorian Village, Columbus, Franklin, Ohio, 43201, United States
COLUMBUS, OH 432013231
Phone: (614) 596-6789
Type: Mailing
750 W HIGH ST STE 300
LIMA, OH 458012967
Phone: (419) 229-6781
Fax: (614) 386-9506
Type: Mailing
NPPES updates history
No NPPES updates recorded for this provider.
Prescription Activity
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Open Payments (CMS)
No Open Payments data available for this provider.
This can happen when there are no reportable CMS Open Payments records.
Medicare Enrollment & Revalidation
Source: CMS public data · Not endorsed by CMS ·
Educational use only—not medical, billing, or legal advice.
PECOS enrollment status
Participating (accepts Medicare assignment)
Enrollment effective: 2018-12-18
PECOS data refreshed: 2026-05-27
Medicare revalidation (CMS due date list)
Past revalidation due date
Earliest CMS due date was 2023-12-31 (891 days ago).
Enrollment records
1
Earliest due date
2023-12-31
CMS data updated
2026-06-01
Revalidation progress
- Medicare enrolled
- On CMS revalidation list
- Due date assigned
- Revalidate in PECOS
CMS enrollment records
| Enrollment ID | Type | Specialty | State | Due date |
|---|---|---|---|---|
| O20181218002595 | O | Clinic/Group Practice | OH | 2023-12-31 |
What to do next
- Verify current status on the CMS Revalidation Lookup Tool immediately.
- Complete revalidation in PECOS or contact your Medicare Administrative Contractor (MAC).
- Overdue revalidation can lead to deactivation of Medicare billing privileges.
Prepare CMS-855 application → · Look up this NPI in PECOS → · Verify on CMS PECOS
Medicare Utilization (FFS)
Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·
Educational use only—not medical, billing, or legal advice.
No Medicare fee-for-service utilization data available for this provider in our database.
Insurance plans in this area (ZIP 45804)
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