Provider Demographics
NPI:1457435133
Name:GRILLO, BRUNO (PA-C)
Entity Type:Individual
Prefix:
First Name:BRUNO
Middle Name:
Last Name:GRILLO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 WHITCHER STREET, SUITE 350
Mailing Address - Street 2:WELLSTAR CARDIOVASCULAR MEDICINE
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-9408
Mailing Address - Country:US
Mailing Address - Phone:770-424-6893
Mailing Address - Fax:678-819-0357
Practice Address - Street 1:55 WHITCHER ST NE
Practice Address - Street 2:SUITE 350
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1155
Practice Address - Country:US
Practice Address - Phone:770-424-6893
Practice Address - Fax:770-424-9095
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004809363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA105882400LMedicaid
GA105882400NMedicaid
GA105882400NMedicaid
GA105882400LMedicaid