Healthcare Provider Details

I. General information

NPI: 1114079589
Provider Name (Legal Business Name): EDMUND A GRILEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: EDMUND A GRILEY GUEVARA

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 11/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

#138 YPAO ROAD
TAMUNING GU
96931
US

IV. Provider business mailing address

PO BOX 315574
TAMUNING GU
96931-3474
US

V. Phone/Fax

Practice location:
  • Phone: 671-646-6111
  • Fax: 671-646-6115
Mailing address:
  • Phone: 671-646-6111
  • Fax: 671-646-6115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberM00714
License Number StateGU

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: