Provider Demographics
NPI:1215030127
Name:GRISOLANO, SCOTT W (MD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:W
Last Name:GRISOLANO
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:PO BOX 843966
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64184-3966
Mailing Address - Country:US
Mailing Address - Phone:573-884-3300
Mailing Address - Fax:573-884-0943
Practice Address - Street 1:ONE HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65212-0001
Practice Address - Country:US
Practice Address - Phone:573-884-8445
Practice Address - Fax:573-884-5318
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004001450207RG0100X
KS04-31624207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208352013Medicaid
KS200358820AMedicaid
MO36111019OtherBCBS KC
MO208352013Medicaid
KSP00278648Medicare ID - Type UnspecifiedRAILROAD MEDICARE
KS200358820AMedicaid