Healthcare Provider Details

I. General information

NPI: 1639178122
Provider Name (Legal Business Name): MICHAEL GRILLON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 11/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20486 MARKET STREET
ONANCOCK VA
23417
US

IV. Provider business mailing address

8262 ATLEE RD SUITE 205
MECHANICSVILLE VA
23116-1816
US

V. Phone/Fax

Practice location:
  • Phone: 757-302-2700
  • Fax: 757-787-9262
Mailing address:
  • Phone: 804-559-0194
  • Fax: 804-559-0198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number0101055534
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101055534
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: