Provider Demographics
NPI:1770771248
Name:MARTHA A. GRISWOLD MD PC
Entity type:Organization
Organization Name:MARTHA A. GRISWOLD MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:A
Authorized Official - Last Name:GRISWOLD
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PC
Authorized Official - Phone:804-861-8444
Mailing Address - Street 1:507 S SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23803-5037
Mailing Address - Country:US
Mailing Address - Phone:804-861-8444
Mailing Address - Fax:804-862-1582
Practice Address - Street 1:507 S SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23803-5037
Practice Address - Country:US
Practice Address - Phone:804-861-8444
Practice Address - Fax:804-862-1582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-10
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101033077207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1770771248OtherNPI
C10320OtherMEDICARE GROUP
VA006097812Medicaid
VA00X534M01Medicare PIN
1770771248OtherNPI