1952414138 NPI number — DR. DEREK GRIMMELL PHD

Table of content: DR. DEREK GRIMMELL PHD (NPI 1952414138)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952414138 NPI number — DR. DEREK GRIMMELL PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRIMMELL
Provider First Name:
DEREK
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
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:
1952414138
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/10/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1523 S BLUFF BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLINTON
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52732-6549
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
563-243-6054
Provider Business Mailing Address Fax Number:
563-243-6828

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3 29TH CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUTCHINSON
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67502-2417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-259-7866
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/15/2006

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: 103TC0700X , with the licence number:  519 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 24558 . This is a "MIDLANDS" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 38434 . This is a "BCBS" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".