Healthcare Provider Details

I. General information

NPI: 1487090288
Provider Name (Legal Business Name): JACK W GRINNAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2013
Last Update Date: 03/21/2025
Certification Date: 03/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2530 E SOUTHERN AVE
MESA AZ
85204-5411
US

IV. Provider business mailing address

10200 GRAND CENTRAL AVE STE 220
OWINGS MILLS MD
21117-4366
US

V. Phone/Fax

Practice location:
  • Phone: 480-834-4188
  • Fax: 480-834-6181
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number55776
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: