Provider Demographics
NPI:1790174993
Name:SCOTT GRIGORY, MD, PC
Entity Type:Organization
Organization Name:SCOTT GRIGORY, MD, PC
Other - Org Name:MY DOCTOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:GRIGORY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-579-3385
Mailing Address - Street 1:1 W MAIN ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:IDABEL
Mailing Address - State:OK
Mailing Address - Zip Code:74745-4654
Mailing Address - Country:US
Mailing Address - Phone:580-579-3385
Mailing Address - Fax:
Practice Address - Street 1:1 W MAIN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:IDABEL
Practice Address - State:OK
Practice Address - Zip Code:74745-4654
Practice Address - Country:US
Practice Address - Phone:580-579-3385
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-12
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK25241208000000X, 208D00000X, 261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200097850AMedicaid