Provider Demographics
NPI:1508974494
Name:GRILLIS, MICHAEL EMANUEL (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:EMANUEL
Last Name:GRILLIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 COUNTY ROAD 398
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:OH
Mailing Address - Zip Code:43420-9253
Mailing Address - Country:US
Mailing Address - Phone:419-334-4383
Mailing Address - Fax:
Practice Address - Street 1:2281 HAYES AVE
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420-2632
Practice Address - Country:US
Practice Address - Phone:419-355-8488
Practice Address - Fax:419-355-8890
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34004664208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0739964Medicaid
OH0739964Medicaid
OH0657153Medicare ID - Type Unspecified
OHH418230Medicare UPIN
OHE48128Medicare UPIN