1972569028 NPI number — MICHAEL D GRIMES MD

Table of content: MICHAEL D GRIMES MD (NPI 1972569028)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972569028 NPI number — MICHAEL D GRIMES MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRIMES
Provider First Name:
MICHAEL
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1972569028
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/08/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8035
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WICHITA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67208-0035
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
316-689-9135
Provider Business Mailing Address Fax Number:
316-689-9667

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1900 N AMIDON AVE
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
WICHITA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67203-2125
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-832-9024
Provider Business Practice Location Address Fax Number:
316-832-9478
Provider Enumeration Date:
04/25/2006

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: 207Q00000X , with the licence number:  04-25925 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100289990D , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003719199 . This is a "MEDICARE" identifier . This identifiers is of the category "OTHER".




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