Provider Demographics
NPI:1417955105
Name:GRISELL, TED W (MD)
Entity Type:Individual
Prefix:DR
First Name:TED
Middle Name:W
Last Name:GRISELL
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 1:10551 N 800 W
Mailing Address - Street 2:
Mailing Address - City:FAIRLAND
Mailing Address - State:IN
Mailing Address - Zip Code:46126-9519
Mailing Address - Country:US
Mailing Address - Phone:317-313-9320
Mailing Address - Fax:317-347-4573
Practice Address - Street 1:10551 N 800 W
Practice Address - Street 2:
Practice Address - City:FAIRLAND
Practice Address - State:IN
Practice Address - Zip Code:46126-9519
Practice Address - Country:US
Practice Address - Phone:317-313-9320
Practice Address - Fax:317-347-4573
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01021489208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery