Healthcare Provider Details

I. General information

NPI: 1619600244
Provider Name (Legal Business Name): KRISTOFFER ROBYN GRYBOW MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2022
Last Update Date: 07/17/2025
Certification Date: 07/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 SKYLINE DR
JACKSON TN
38301-3923
US

IV. Provider business mailing address

750 BROADWAY STE 350
FORT WAYNE IN
46802-1412
US

V. Phone/Fax

Practice location:
  • Phone: 219-242-3431
  • Fax:
Mailing address:
  • Phone: 260-423-2675
  • Fax: 260-423-6621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11022599A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number74073
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: