1447282116 NPI number — DR. TRACEY P GRIM MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447282116 NPI number — DR. TRACEY P GRIM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRIM
Provider First Name:
TRACEY
Provider Middle Name:
P
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1447282116
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
777 LOWNDES HILL RD BLDG 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29607-2101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-967-2289
Provider Business Mailing Address Fax Number:
855-621-7065

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 WELLNESS WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILFORD
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19963-4364
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-422-3311
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  MD044957E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: C1-0011097 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1142786 . This is a "AMERIHEALTHMERCY- WMG" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 5272418 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 80744 . This is a "UNISON- WMG" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 02016202 . This is a "CAPITAL BLUE CROSS-WMG" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1506605 . This is a "GATEWAY- WMG" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 348539 . This is a "MAMSI-ALLIANCE - WMG" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 524956 . This is a "CAREFIRST MD BCBS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 001250840 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 32662 . This is a "JOHNS HOPKINS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 39193 . This is a "GEISINGER HEALTH PLAN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 662061 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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