Provider Demographics
NPI:1851309165
Name:GRENFELL, JR., RAYMOND F (MD)
Entity type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:F
Last Name:GRENFELL, JR.
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1151 N STATE ST
Mailing Address - Street 2:SUITE 601
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2407
Mailing Address - Country:US
Mailing Address - Phone:601-948-5158
Mailing Address - Fax:601-949-6058
Practice Address - Street 1:1151 N STATE ST
Practice Address - Street 2:SUITE 601
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2407
Practice Address - Country:US
Practice Address - Phone:601-948-5158
Practice Address - Fax:601-949-6058
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS07011207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00017558Medicaid
MSB66221Medicare UPIN
MS460000018Medicare ID - Type Unspecified