Healthcare Provider Details

I. General information

NPI: 1578740205
Provider Name (Legal Business Name): HAROLD J GRISSOM CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2008
Last Update Date: 05/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2520 5TH ST N
COLUMBUS MS
39705-2008
US

IV. Provider business mailing address

29 CREAMERY LN
EASTON MD
21601-3137
US

V. Phone/Fax

Practice location:
  • Phone: 662-244-1000
  • Fax: 662-327-6004
Mailing address:
  • Phone: 800-222-1335
  • Fax: 800-222-1335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR857989
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: