Basic Information
| Provider Information | |||||||||
| NPI: | 1639117328 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRIGUTIS | ||||||||
| FirstName: | EILEEN | ||||||||
| MiddleName: | O'NEIL | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 E BROADWAY | ||||||||
| Address2: | STE 290 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022178221 | ||||||||
| FaxNumber: | 5022175056 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 S JACKSON ST | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025626511 | ||||||||
| FaxNumber: | 5025626512 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 11/18/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3333P | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 200942760 | 05 | IN | MEDICAID | 536489 | 01 | KY | ANTHEM | OTHER | 7100049340 | 05 | KY | MEDICAID | 50016607 | 01 | KY | PASSPORT HEALTH PLAN | OTHER |