Provider Demographics
NPI:1740260769
Name:GRISHAW, EDWARD KENNETH (MD)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:KENNETH
Last Name:GRISHAW
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:PO BOX 886
Mailing Address - Street 2:131 W 2ND ST
Mailing Address - City:RUTHERFORDTON
Mailing Address - State:NC
Mailing Address - Zip Code:28139-0886
Mailing Address - Country:US
Mailing Address - Phone:828-287-2984
Mailing Address - Fax:828-287-3582
Practice Address - Street 1:288 S RIDGECREST AVE
Practice Address - Street 2:
Practice Address - City:RUTHERFORDTON
Practice Address - State:NC
Practice Address - Zip Code:28139
Practice Address - Country:US
Practice Address - Phone:828-286-5335
Practice Address - Fax:828-286-5231
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC94012042085R0202X
TXJ41712085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8937461Medicaid
G23209Medicare UPIN
NC2220873AMedicare ID - Type Unspecified