Provider Demographics
NPI:1154621787
Name:GRISE, JERRY WADE (MD)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:WADE
Last Name:GRISE
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 1:1661 INTERNATIONAL PLACE DRIVE
Mailing Address - Street 2:SUITE 350
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120
Mailing Address - Country:US
Mailing Address - Phone:901-685-2696
Mailing Address - Fax:
Practice Address - Street 1:2405 SNOWBERRY CIR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-3576
Practice Address - Country:US
Practice Address - Phone:573-442-0003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-29
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN29332085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology