Basic Information
| Provider Information | |||||||||
| NPI: | 1487090288 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRINNAN | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 77 E THOMAS RD STE 230 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850123100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6025570007 | ||||||||
| FaxNumber: | 6025570002 | ||||||||
| Practice Location | |||||||||
| Address1: | 19841 N 27TH AVE STE 201 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850274005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235826420 | ||||||||
| FaxNumber: | 6235826720 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2013 | ||||||||
| LastUpdateDate: | 08/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208800000X | 55776 | AZ | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 372496 | 05 | AZ | MEDICAID |