Healthcare Provider Details

I. General information

NPI: 1982901856
Provider Name (Legal Business Name): PAUL MICHAEL LEE GRENELLE P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2011
Last Update Date: 01/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 NO. CLYDE MORRIS BLVD. HALIFAX MEDICAL CENTER
DAYTONA BEACH FL
32114-2709
US

IV. Provider business mailing address

PO BOX 864074 HALIFAX HEALTHCARE SYSTEMS, INC.
ORLANDO FL
32886-4074
US

V. Phone/Fax

Practice location:
  • Phone: 386-425-2285
  • Fax: 386-425-7522
Mailing address:
  • Phone: 386-226-4590
  • Fax: 386-226-3371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9105871
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9105871
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: