Healthcare Provider Details

I. General information

NPI: 1326508805
Provider Name (Legal Business Name): PHILLIP THOMAS GRISDELA JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2019
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BREWSTER BLVD
CAMP LEJEUNE NC
28547-2575
US

IV. Provider business mailing address

100 BREWSTER BLVD
CAMP LEJEUNE NC
28547-2575
US

V. Phone/Fax

Practice location:
  • Phone: 910-450-4357
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberA194489
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number2025-02933
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License NumberA194489
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: