Provider Demographics
NPI:1952467060
Name:GRILL, ALISSA MICHELLE
Entity Type:Individual
Prefix:DR
First Name:ALISSA
Middle Name:MICHELLE
Last Name:GRILL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 E OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-3506
Mailing Address - Country:US
Mailing Address - Phone:516-889-0100
Mailing Address - Fax:516-897-2425
Practice Address - Street 1:10 FRANKLIN BLVD
Practice Address - Street 2:SUITE #102
Practice Address - City:LONG BEACH
Practice Address - State:NY
Practice Address - Zip Code:11561-4501
Practice Address - Country:US
Practice Address - Phone:516-889-0100
Practice Address - Fax:516-897-2425
Is Sole Proprietor?:No
Enumeration Date:2007-01-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY194998207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01735744Medicaid
NY01735744Medicaid