Healthcare Provider Details

I. General information

NPI: 1659898211
Provider Name (Legal Business Name): ANTHONY MICHAEL GRILLIOT CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2017
Last Update Date: 03/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 BELLEFONTAINE AVE
LIMA OH
45804-2800
US

IV. Provider business mailing address

1825 BARNHART RD
TROY OH
45373-9589
US

V. Phone/Fax

Practice location:
  • Phone: 419-228-3335
  • Fax:
Mailing address:
  • Phone: 937-552-9420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.345017
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN.CRNA.019559
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: