Provider Demographics
NPI:1245331768
Name:GRILLO, MARSHALL SALVATORE SR (DO)
Entity type:Individual
Prefix:DR
First Name:MARSHALL
Middle Name:SALVATORE
Last Name:GRILLO
Suffix:SR
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 1:909 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:GLADWIN
Mailing Address - State:MI
Mailing Address - Zip Code:48624-1048
Mailing Address - Country:US
Mailing Address - Phone:989-426-8228
Mailing Address - Fax:989-426-8228
Practice Address - Street 1:5239 GROVE MNR
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-3527
Practice Address - Country:US
Practice Address - Phone:352-753-7591
Practice Address - Fax:352-753-7591
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010054922085B0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI11137932410267Medicaid
MI11137932410267Medicaid
57706905302Medicare ID - Type Unspecified