Provider Demographics
NPI:1376596833
Name:GRIGG, WENDELL RANDOLPH JR (MD)
Entity Type:Individual
Prefix:
First Name:WENDELL
Middle Name:RANDOLPH
Last Name:GRIGG
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 1:859 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27605-3259
Mailing Address - Country:US
Mailing Address - Phone:919-828-9937
Mailing Address - Fax:919-828-4287
Practice Address - Street 1:859 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27605-3259
Practice Address - Country:US
Practice Address - Phone:919-828-9937
Practice Address - Fax:919-828-4287
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC173622084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCD33016Medicare UPIN
NC201787DMedicare ID - Type Unspecified