Basic Information
| Provider Information | |||||||||
| NPI: | 1770513913 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRENVIK | ||||||||
| FirstName: | STEFAN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 350 BLOUNTVILLE HWY | ||||||||
| Address2: | SUITE 207 | ||||||||
| City: | BRISTOL | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376200213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239684540 | ||||||||
| FaxNumber: | 4239685697 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 MEDICAL PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | BRISTOL | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376207430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239684540 | ||||||||
| FaxNumber: | 4239685697 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 03/12/2009 | ||||||||
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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 | 207L00000X | MD024364 | TN | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | BG3585328 | 01 | TN | DEA | OTHER |