Basic Information
| Provider Information | |||||||||
| NPI: | 1700836335 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRISSON | ||||||||
| FirstName: | ALLEN | ||||||||
| MiddleName: | TRACY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5370 | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756085370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036634800 | ||||||||
| FaxNumber: | 9036630378 | ||||||||
| Practice Location | |||||||||
| Address1: | 1204 N MOUND ST | ||||||||
| Address2: | RADIOLOGY DEPARTMENT | ||||||||
| City: | NACOGDOCHES | ||||||||
| State: | TX | ||||||||
| PostalCode: | 759614027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9365688514 | ||||||||
| FaxNumber: | 9036630378 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 12/20/2011 | ||||||||
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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 | 2085R0202X | K3580 | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 047351401 | 05 | TX | MEDICAID |