Provider Demographics
NPI:1639178122
Name:GRILLON, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:GRILLON
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 1:8262 ATLEE RD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:MECHANICSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23116-1816
Mailing Address - Country:US
Mailing Address - Phone:804-559-0194
Mailing Address - Fax:804-559-0198
Practice Address - Street 1:20486 MARKET STREET
Practice Address - Street 2:
Practice Address - City:ONANCOCK
Practice Address - State:VA
Practice Address - Zip Code:23417
Practice Address - Country:US
Practice Address - Phone:757-302-2700
Practice Address - Fax:757-787-9262
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101055534208600000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC06115OtherGROUP PTAN
WV1073988OtherBRICKSTREET-WV COMP
VA1639178122Medicaid
VA020002600OtherBLACK LUNG
VA2132448OtherMAMSI
VA5472512OtherAETNA
NC790577TMedicaid
VA1373138OtherCIGNA
VA178223OtherBCBS
WV3810012912Medicaid
WV1073988OtherBRICKSTREET-WV COMP
VA1373138OtherCIGNA
NC790577TMedicaid
VA018215C10Medicare PIN
VA1639178122Medicaid