Provider Demographics
NPI:1972575694
Name:GRISWOLD, MICHAEL SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SCOTT
Last Name:GRISWOLD
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 1:103 BUSINESS HWY 54 NORTH
Mailing Address - Street 2:
Mailing Address - City:ELDON
Mailing Address - State:MO
Mailing Address - Zip Code:65026
Mailing Address - Country:US
Mailing Address - Phone:573-392-2124
Mailing Address - Fax:573-392-6375
Practice Address - Street 1:103 BUSINESS HWY 54 NORTH
Practice Address - Street 2:
Practice Address - City:ELDON
Practice Address - State:MO
Practice Address - Zip Code:65026
Practice Address - Country:US
Practice Address - Phone:573-392-2124
Practice Address - Fax:573-392-6375
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO108169207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
440546366OtherUNITED HEALTHCARE
10582ROtherBLUE CROSS BLUE SHIELD
MO208705616Medicaid
G50237OtherMERCY
CH5818OtherRR MEDICARE
3108991OtherCIGNA
389142OtherHEALTHLINK
010060877OtherRR MEDICARE
G50237Medicare UPIN
389142OtherHEALTHLINK
000012098Medicare ID - Type Unspecified