Bruce Grissom Jr.
Individual provider Active NPI Family Medicine Physician · Purvis, MS
NPI 1720513617 · NPPES record last updated Aug 27, 2020
Key facts
- NPI
- 1720513617
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Family Medicine Physician 207Q00000X
- License
- 27862 (MS)
- Practice address
- 102 Shelby Speights Dr
Purvis, MS 39475-4151 - Phone
- (601) 794-8065
- Fax
- (601) 794-5650
- NPI assigned
- Apr 27, 2017
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 3
Hospital & facility affiliations 3
Medicare Care Compare profile
- Specialty
- Family Practice
- Education
- William Carey University College of Osteopathic Medicine, 2017
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
- Group practices
- Hattiesburg Clinic PA
Practice addresses (Care Compare)
415 S 28TH Ave
Hattiesburg, MS 39401-7246
Phone (601) 264-6000
Hospital & facility affiliations
- Forrest General Home Care
- Enhabit Home Health & Hospice
- Forrest General Hospital
Procedures performed for Medicare patients
| Procedure | Number of procedures |
|---|---|
| Removal of skin lesions | 1-10 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MS
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20200730002968 | MS | Practitioner - Family Practice | 5496170987 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Doctor of Osteopathy
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Hattiesburg Clinic, PA | Current |
Accepting new patients | |
| Hattiesburg Clinic PA | Current |
Accepting new patients | |
| Hattiesburg Clinic, PA | Past | Accepting new patients |
Locations
415 S 28th Ave
Hattiesburg, MS 39401
Phone (601) 261-3606
102 Shelby Speights Dr
Purvis, MS 39475
Phone (601) 794-8065
Interoperability endpoints
- bgrissom102067@directpatientrecord.com
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | 27862 | MS | Yes |
Addresses
Primary practice location
102 Shelby Speights Dr
Purvis, MS 39475-4151
Mailing address
415 S 28TH Ave
Hattiesburg, MS 39401-7246
Phone (601) 794-8065
Electronic endpoints
| Type | Endpoint | Use | Affiliation |
|---|---|---|---|
| Direct Messaging Address | bgrissom102067@directpatientrecord.com | Health Information Exchange (HIE) |
Other providers in Purvis, MS
- Keeley Gardner
- Angela Crabtree Gatlin
- Christopher Gleason
- Ashley Gray
- Sharon Griffin
- Candice Cartwright Hamilton
- Mindy L Hamilton
- Muneeb Haq
- Stephen L Harless
- Nicholas E Hartley
All providers in Purvis, MS · Family Medicine Physician in Mississippi
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Aug 27, 2020. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.