Basic Information
| Provider Information | |||||||||
| NPI: | 1215963442 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRISE | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | ANDREW | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2699 | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325132699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504754500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5151 N 9TH AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325048721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504164970 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | ME95178 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | ME110993 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 1140619 | 05 | LA | MEDICAID | 05483588 | 05 | MS | MEDICAID | ME95178 | 01 | FL | MEDICAL LICENSE | OTHER |