Provider Demographics
NPI:1720168727
Name:GRIGG, JON R (MD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:R
Last Name:GRIGG
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 1:1873 SHUMWAY HILL RD
Mailing Address - Street 2:
Mailing Address - City:WELLSBORO
Mailing Address - State:PA
Mailing Address - Zip Code:16901-6840
Mailing Address - Country:US
Mailing Address - Phone:570-724-5766
Mailing Address - Fax:570-724-6757
Practice Address - Street 1:ST. JAMES & THIRD STREET
Practice Address - Street 2:SUITE 103A
Practice Address - City:MANSFIELD
Practice Address - State:PA
Practice Address - Zip Code:16933
Practice Address - Country:US
Practice Address - Phone:570-662-7600
Practice Address - Fax:570-662-7726
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD043534E2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011677250013Medicaid
PA0011677250014Medicaid
PA0011677250014Medicaid