MEDICARE: DR. JOHN HAROLD GRIDER D.O.

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	207RC0200X	Critical Care Medicine (Internal Medicine) Physician	O1384	ID
2	208M00000X	Hospitalist Physician	O1384	ID
3	207R00000X	Internal Medicine Physician	O1384	ID

General Provider Information

NPI Number	:	1568796654
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN HAROLD GRIDER D.O.

Provider Business Mailing Address
First Line	:	PO BOX 742337
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-2337
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2860 CHANNING WAY STE 221
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-7541
Country	:	US
Telephone Number	:	208-535-4000
Fax Number	:	208-535-4014

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

Provider Enumeration Date	:	09/23/2009
Last Update Date	:	03/03/2022

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