Provider Demographics
NPI:1578740205
Name:GRISSOM, HAROLD J (CRNA)
Entity Type:Individual
Prefix:
First Name:HAROLD
Middle Name:J
Last Name:GRISSOM
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 CREAMERY LN
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:MD
Mailing Address - Zip Code:21601-3137
Mailing Address - Country:US
Mailing Address - Phone:800-222-1335
Mailing Address - Fax:800-222-1335
Practice Address - Street 1:2520 5TH ST N
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-2008
Practice Address - Country:US
Practice Address - Phone:662-244-1000
Practice Address - Fax:662-327-6004
Is Sole Proprietor?:No
Enumeration Date:2008-01-24
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR857989367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS149323637OtherTRI-CARE
MS04438041Medicaid
MS04438041Medicaid