MEDICARE: ALLEN TRACY GRISSON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	K3580	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1700836335
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALLEN TRACY GRISSON M.D.

Provider Business Mailing Address
First Line	:	PO BOX 5370
Second Line	:
City	:	LONGVIEW
State	:	TX
Zip	:	75608-5370
Country	:	US
Telephone Number	:	903-663-4800
Fax Number	:	903-663-0378

Provider Business Practice Location Address
First Line	:	1204 N MOUND ST
Second Line	:	RADIOLOGY DEPARTMENT
City	:	NACOGDOCHES
State	:	TX
Zip	:	75961-4027
Country	:	US
Telephone Number	:	936-568-8514
Fax Number	:	903-663-0378

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/12/2006
Last Update Date	:	12/20/2011

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