Provider Demographics
NPI:1801057658
Name:GRISSOM, RUTH ANNE (MD)
Entity type:Individual
Prefix:
First Name:RUTH
Middle Name:ANNE
Last Name:GRISSOM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4901 GRANDE DR
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-5935
Mailing Address - Country:US
Mailing Address - Phone:850-477-7043
Mailing Address - Fax:850-474-9060
Practice Address - Street 1:4901 GRANDE DR
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-5935
Practice Address - Country:US
Practice Address - Phone:850-477-7043
Practice Address - Fax:850-474-9060
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME102001207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL131403Medicaid
FL000328600Medicaid
AL592-03468OtherBLUE CROSS BLUE SHIELD
AL592-15483OtherBLUE CROSS BLUE SHIELD
P00667073OtherMEDICARE RAILROAD
FL61672OtherBLUE CROSS BLUE SHIELD
AL103990Medicaid
AL131403Medicaid