Healthcare Provider Details

I. General information

NPI: 1790828119
Provider Name (Legal Business Name): TIMOTHY D GRINNELL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 WINTER ST
WALTHAM MA
02451-1433
US

IV. Provider business mailing address

110 LIBERTY ST
BROCKTON MA
02301-5521
US

V. Phone/Fax

Practice location:
  • Phone: 781-890-2133
  • Fax: 781-890-2177
Mailing address:
  • Phone: 508-565-3055
  • Fax: 508-894-0757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2274
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: