Provider Demographics
NPI:1720513617
Name:GRISSOM, BRUCE JR
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:
Last Name:GRISSOM
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-794-8065
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:102 SHELBY SPEIGHTS DR
Practice Address - Street 2:
Practice Address - City:PURVIS
Practice Address - State:MS
Practice Address - Zip Code:39475-4151
Practice Address - Country:US
Practice Address - Phone:601-794-8065
Practice Address - Fax:601-794-5650
Is Sole Proprietor?:No
Enumeration Date:2017-04-27
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS27862207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine