Provider Demographics
NPI:1073165163
Name:GRILLO, SAMUEL
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:GRILLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4753 ELIZABETHTOWN RD
Mailing Address - Street 2:
Mailing Address - City:MANHEIM
Mailing Address - State:PA
Mailing Address - Zip Code:17545-8369
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 N COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:ANNVILLE
Practice Address - State:PA
Practice Address - Zip Code:17003-1404
Practice Address - Country:US
Practice Address - Phone:717-341-3123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-10
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program