Provider Demographics
NPI:1891830402
Name:GRISSOM, BRADLEY (NP)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:GRISSOM
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 6002
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61803-6002
Mailing Address - Country:US
Mailing Address - Phone:217-326-8300
Mailing Address - Fax:
Practice Address - Street 1:2300 N. VERMILION AVENUE
Practice Address - Street 2:MEDICAL SUB-SPECIALTIES
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832
Practice Address - Country:US
Practice Address - Phone:217-554-1700
Practice Address - Fax:217-554-1704
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2010-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209005691363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q52854Medicare UPIN
ILQ52854Medicare UPIN
IL6447860016Medicare NSC
ILIL3270085Medicare PIN