1275698953 NPI number — TERRY V. GRUELLE P.S.C.

Table of content: (NPI 1275698953)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275698953 NPI number — TERRY V. GRUELLE P.S.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TERRY V. GRUELLE P.S.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1275698953
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
40 N GRAND AVE
Provider Second Line Business Mailing Address:
SUITE 301
Provider Business Mailing Address City Name:
FORT THOMAS
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41075-4107
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-441-2369
Provider Business Mailing Address Fax Number:
859-442-3222

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
40 N GRAND AVE
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
FORT THOMAS
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41075-4107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-441-2369
Provider Business Practice Location Address Fax Number:
859-442-3222
Provider Enumeration Date:
12/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GRUELLE
Authorized Official First Name:
TERRY
Authorized Official Middle Name:
VERNON
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
859-391-4000

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X , with the licence number:  4118 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6004118300 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com