Provider Demographics
NPI:1649767450
Name:GRILLO, NICHOLAS (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:GRILLO
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 1:35 MEDICAL CENTER PKWY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-8160
Mailing Address - Country:US
Mailing Address - Phone:207-248-5000
Mailing Address - Fax:207-626-1648
Practice Address - Street 1:35 MEDICAL CENTER PKWY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-8160
Practice Address - Country:US
Practice Address - Phone:207-248-5000
Practice Address - Fax:207-626-1648
Is Sole Proprietor?:No
Enumeration Date:2018-04-17
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MEMD24449207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program