Provider Demographics
NPI:1730114448
Name:GRILLO, MARSHALL SALVATORE JR (DO)
Entity Type:Individual
Prefix:
First Name:MARSHALL
Middle Name:SALVATORE
Last Name:GRILLO
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 HEALTH PARK BLVD
Mailing Address - Street 2:STE G
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-2558
Mailing Address - Country:US
Mailing Address - Phone:810-606-1660
Mailing Address - Fax:810-606-1655
Practice Address - Street 1:600 HEALTH PARK BLVD
Practice Address - Street 2:STE G
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-2558
Practice Address - Country:US
Practice Address - Phone:810-606-1660
Practice Address - Fax:810-606-1655
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN22052086S0129X
KYTP0532086S0129X
PAOS010217L2086S0129X
VA01022032572086S0129X
MI51010110252086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1730114448Medicaid
PA0017202200012Medicaid
PA821942Other1ST PRIORITY HEALTHCARE
KY000000566339OtherANTHEM
PA176254OtherBS HIGHMARK
VA1730114448Medicaid
KY000000566339OtherANTHEM
VAP01136744Medicare PIN
PA021148Medicare PIN
MIPENDINGMedicare PIN