Basic Information
| Provider Information | |||||||||
| NPI: | 1366599243 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRIPPO | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | AARON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3239 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462063239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8442954871 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1224 TROTWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 384014802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9313881286 | ||||||||
| FaxNumber: | 9313887119 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2007 | ||||||||
| LastUpdateDate: | 08/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 39219 | TN | N | Other Service Providers | Specialist | 2085R0202X | MD | TN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 000000623463 | 01 | KY | ANTHEM BC | OTHER | 4191316 | 01 | TN | BCBS TN | OTHER | P00725889 | 01 | RAILROAD MEDICARE | OTHER | 1505378 | 05 | TN | MEDICAID |