Provider Demographics
NPI:1629042122
Name:GRISHAM, ANDRE D (MD)
Entity Type:Individual
Prefix:
First Name:ANDRE
Middle Name:D
Last Name:GRISHAM
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 1:800 SW 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1902
Mailing Address - Country:US
Mailing Address - Phone:503-221-0161
Mailing Address - Fax:
Practice Address - Street 1:9250 SW HALL BLVD
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-6721
Practice Address - Country:US
Practice Address - Phone:503-221-0161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC29462208600000X
TN38146208600000X
ORMD151172208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3895467Medicaid
TN4214668OtherBCBS TN
MS04951725Medicaid
TN4214668OtherBCBS TN
TN103I023482Medicare PIN
IO5564Medicare UPIN
TN38954671Medicare PIN