Gary    Grindstaff    DPM
Contract Details
Ancillary Care Services
Facility name
Provider ID
P000005616
NPI
1912995895
Tax ID
208279679
Effective Date
4/1/2012
Last Updated
10/22/2013
Direct Contract
No
Status
Active
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
88.00
Location Details
Address
5547 North Mesa Street Suite A
El Paso, TX 79912
United States
County
El Paso
Phone
9158455000 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Podiatry
Map
Address