1720168727 NPI number — JON R GRIGG MD

Table of content: JON R GRIGG MD (NPI 1720168727)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720168727 NPI number — JON R GRIGG MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRIGG
Provider First Name:
JON
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1720168727
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/05/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1873 SHUMWAY HILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WELLSBORO
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16901-6840
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-724-5766
Provider Business Mailing Address Fax Number:
570-724-6757

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
ST. JAMES & THIRD STREET
Provider Second Line Business Practice Location Address:
SUITE 103A
Provider Business Practice Location Address City Name:
MANSFIELD
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16933
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-662-7600
Provider Business Practice Location Address Fax Number:
570-662-7726
Provider Enumeration Date:
10/16/2006

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: 2084P0800X , with the licence number:  MD043534E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0011677250013 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0011677250014 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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