Provider Demographics
NPI:1538142328
Name:GRISCOM, ANDREW (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:GRISCOM
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 1:111 BREWSTER ST
Mailing Address - Street 2:DEPARTMENT OF EMERGENCY MEDICINE
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-4400
Mailing Address - Country:US
Mailing Address - Phone:401-729-2191
Mailing Address - Fax:401-729-2517
Practice Address - Street 1:111 BREWSTER ST
Practice Address - Street 2:DEPARTMENT OF EMERGENCY MEDICINE
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-4400
Practice Address - Country:US
Practice Address - Phone:401-729-2191
Practice Address - Fax:401-729-2517
Is Sole Proprietor?:No
Enumeration Date:2005-11-25
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD09664207P00000X
CT34668207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI007061007OtherMEDICARE PTAN
RI7006158Medicaid
RI007061007OtherMEDICARE PTAN