1285191049 NPI number — MRS. SHANDRA LADELL GRIMES NP

Table of content: MRS. SHANDRA LADELL GRIMES NP (NPI 1285191049)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285191049 NPI number — MRS. SHANDRA LADELL GRIMES NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRIMES
Provider First Name:
SHANDRA
Provider Middle Name:
LADELL
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
NP
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:
1285191049
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/22/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7351 OLD MOON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31909-7291
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-653-7000
Provider Business Mailing Address Fax Number:
706-653-7800

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2300 MANCHESTER EXPWY ST FRANCIS HOSPITAL
Provider Second Line Business Practice Location Address:
SUITE C-001
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31904
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-596-4000
Provider Business Practice Location Address Fax Number:
706-320-8327
Provider Enumeration Date:
02/27/2019

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: 363LG0600X , with the licence number:  RN142131 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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