1083714380 NPI number — STEPHEN G GRILLOT D.O.

Table of content: STEPHEN G GRILLOT D.O. (NPI 1083714380)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083714380 NPI number — STEPHEN G GRILLOT D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRILLOT
Provider First Name:
STEPHEN
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083714380
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/20/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2021 N AMIDON AVE STE 13
Provider Second Line Business Mailing Address:
P.O. BOX 1179
Provider Business Mailing Address City Name:
WICHITA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67203-2100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
316-832-0833
Provider Business Mailing Address Fax Number:
316-219-2990

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
132 W A AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KINGMAN
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67068-1305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-532-5800
Provider Business Practice Location Address Fax Number:
620-532-3361
Provider Enumeration Date:
09/25/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  05-25303 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100237500F , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100237500O , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00829200 . This is a "RAILROAD THRU ST CATS" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".