Healthcare Provider Details

I. General information

NPI: 1972575694
Provider Name (Legal Business Name): MICHAEL SCOTT GRISWOLD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2006
Last Update Date: 06/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 BUSINESS HWY 54 NORTH
ELDON MO
65026
US

IV. Provider business mailing address

103 BUSINESS HWY 54 NORTH
ELDON MO
65026
US

V. Phone/Fax

Practice location:
  • Phone: 573-392-2124
  • Fax: 573-392-6375
Mailing address:
  • Phone: 573-392-2124
  • Fax: 573-392-6375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number108169
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: