Provider Demographics
NPI:1184636003
Name:GRIGSBY, CHARLES GARY JR (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:GARY
Last Name:GRIGSBY
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 WEST WALNUT STREET
Mailing Address - Street 2:
Mailing Address - City:PANVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40422
Mailing Address - Country:US
Mailing Address - Phone:859-239-5870
Mailing Address - Fax:859-239-5879
Practice Address - Street 1:216 WEST WALNUT STREET
Practice Address - Street 2:
Practice Address - City:PANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422
Practice Address - Country:US
Practice Address - Phone:859-239-5870
Practice Address - Fax:859-239-5879
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY24735207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYC78315Medicare UPIN