Provider Demographics
NPI:1205824265
Name:GRISSOM, SAMUEL (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:GRISSOM
Suffix:
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 1:8391 N DAVIS HWY
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-6048
Mailing Address - Country:US
Mailing Address - Phone:850-494-6000
Mailing Address - Fax:866-947-4181
Practice Address - Street 1:8391 N DAVIS HWY
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514
Practice Address - Country:US
Practice Address - Phone:850-494-6000
Practice Address - Fax:866-947-4181
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS192192081P0004X, 208100000X
FLME61914208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P0004XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSpinal Cord Injury Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS2554707Medicaid
F91995Medicare UPIN
F91995Medicare UPIN