1407816176 NPI number — WILLIAM ARCHIE GRIMSLEY JR. DO

Table of content: (NPI 1740236272)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407816176 NPI number — WILLIAM ARCHIE GRIMSLEY JR. DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRIMSLEY
Provider First Name:
WILLIAM
Provider Middle Name:
ARCHIE
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
DO
Provider Gender Code:
M

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:
1407816176
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/30/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 20169
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROANOKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24018-0506
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3500 ARENDELL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOREHEAD CITY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28557
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-808-6074
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/25/2006

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: 207ZP0102X , with the licence number:  32712 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8937682 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 37682 . This is a "BCBS OF NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 220015619 . This is a "RR MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".