Provider Demographics
NPI:1568781441
Name:GRIEP, SCOTT M (MS, PA, ATC)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:M
Last Name:GRIEP
Suffix:
Gender:M
Credentials:MS, PA, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:744 S WEBSTER AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-3505
Mailing Address - Country:US
Mailing Address - Phone:920-433-9621
Mailing Address - Fax:920-433-0565
Practice Address - Street 1:720 S VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3538
Practice Address - Country:US
Practice Address - Phone:920-433-9621
Practice Address - Fax:920-433-0565
Is Sole Proprietor?:No
Enumeration Date:2010-05-18
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2582-23363A00000X
WI3179-23363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WICG7604Medicare Oscar/Certification
WI07690Medicare PIN
WI002150293Medicare Oscar/Certification