Basic Information
| Provider Information | |||||||||
| NPI: | 1720029275 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRAYSON | ||||||||
| FirstName: | PATRICK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 636019 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452636019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8659857234 | ||||||||
| FaxNumber: | 8659857077 | ||||||||
| Practice Location | |||||||||
| Address1: | 1850 OLD KNOXVILLE RD | ||||||||
| Address2: | |||||||||
| City: | TAZEWELL | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378793625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236264211 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 06/12/2008 | ||||||||
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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 | 207P00000X | 36478 | TN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | MD.13301R | LA | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1561100 | 05 | LA | MEDICAID | 4067317 | 01 | TN | BCBS OF TENNESSEE | OTHER | P00255392 | 01 | TN | RAILROAD MEDICARE | OTHER | 3875615 | 05 | TN | MEDICAID | 010256682 | 05 | VA | MEDICAID |