MEDICARE: ERIN GRISSMAN RT(R)(ARRT)

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	247100000X	Radiologic Technologist	461593	NM

General Provider Information

NPI Number	:	1265982870
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERIN GRISSMAN RT(R)(ARRT)

Provider Business Mailing Address
First Line	:	3260 VENUS ST
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88012-7753
Country	:	US
Telephone Number	:	806-773-4999
Fax Number	:

Provider Business Practice Location Address
First Line	:	3260 VENUS ST
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88012-7753
Country	:	US
Telephone Number	:	806-773-4999
Fax Number	:

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

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

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