Provider Demographics
NPI:1619296795
Name:GRIBBEN, WALTER BLAKE (MD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:BLAKE
Last Name:GRIBBEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1440 NARROW LANE PKWY
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36111-2654
Mailing Address - Country:US
Mailing Address - Phone:334-281-4140
Mailing Address - Fax:334-281-4198
Practice Address - Street 1:1440 NARROW LANE PKWY
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36111-2654
Practice Address - Country:US
Practice Address - Phone:334-281-4140
Practice Address - Fax:334-281-4198
Is Sole Proprietor?:No
Enumeration Date:2010-05-27
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014012620208000000X, 2080P0204X, 208M00000X
ALMD.42619207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILENROLLEDMedicaid
AL268374Medicaid