MEDICARE: KEVIN GRIERSON DPM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213ES0103X	Foot & Ankle Surgery Podiatrist	0116029440	VA

General Provider Information

NPI Number	:	1154770048
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN GRIERSON DPM

Provider Business Mailing Address
First Line	:	2281 CLEVELAND AVE
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95403-2905
Country	:	US
Telephone Number	:	707-544-3337
Fax Number	:

Provider Business Practice Location Address
First Line	:	2281 CLEVELAND AVE
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95403-2905
Country	:	US
Telephone Number	:	707-544-3337
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/10/2016
Last Update Date	:	06/25/2019

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