Healthcare Provider Details

I. General information

NPI: 1790174993
Provider Name (Legal Business Name): SCOTT GRIGORY, MD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2015
Last Update Date: 10/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 W MAIN ST SUITE 100
IDABEL OK
74745-4654
US

IV. Provider business mailing address

1 W MAIN ST SUITE 100
IDABEL OK
74745-4654
US

V. Phone/Fax

Practice location:
  • Phone: 580-579-3385
  • Fax:
Mailing address:
  • Phone: 580-579-3385
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25241
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number25241
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number25241
License Number StateOK

VIII. Authorized Official

Name: DR. SCOTT MARTIN GRIGORY
Title or Position: OWNER
Credential: M.D.
Phone: 580-579-3385