Provider Demographics
NPI:1366423980
Name:GRILLOT, MICHAEL B (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:B
Last Name:GRILLOT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1906 BLAKE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD SPGS
Mailing Address - State:CO
Mailing Address - Zip Code:81601-4227
Mailing Address - Country:US
Mailing Address - Phone:970-384-7140
Mailing Address - Fax:970-384-7293
Practice Address - Street 1:1906 BLAKE AVE
Practice Address - Street 2:
Practice Address - City:GLENWOOD SPGS
Practice Address - State:CO
Practice Address - Zip Code:81601-4227
Practice Address - Country:US
Practice Address - Phone:970-384-7140
Practice Address - Fax:970-384-7293
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO106801207XS0106X
CO54940207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR128583001Medicaid
MOP01085134OtherMCR RR
MO1366423980Medicaid
MO431560263OtherTRICARE
MO132680324Medicare PIN