Provider Demographics
NPI:1942547450
Name:GRISSOM, THOMAS R (SFIDC)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:R
Last Name:GRISSOM
Suffix:
Gender:M
Credentials:SFIDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:NAVAL MOBILE CONSTRUCTION BATTALION ONE
Mailing Address - Street 2:UNIT 60251
Mailing Address - City:FPO
Mailing Address - State:AA
Mailing Address - Zip Code:34099-4900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:NAVAL MOBILE CONSTRUCTION BATTALION ONE
Practice Address - Street 2:UNIT 60251
Practice Address - City:FPO
Practice Address - State:AA
Practice Address - Zip Code:34099-4900
Practice Address - Country:US
Practice Address - Phone:619-806-7925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-04
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman