Provider Demographics
NPI:1073732061
Name:GRIMM, MICHAEL J (APN)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:J
Last Name:GRIMM
Suffix:
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 N HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-1449
Mailing Address - Country:US
Mailing Address - Phone:630-801-5700
Mailing Address - Fax:
Practice Address - Street 1:1325 N HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-1449
Practice Address - Country:US
Practice Address - Phone:630-801-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-004979363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK23845Medicare ID - Type UnspecifiedMEMBER NUMBER
ILK23844Medicare ID - Type UnspecifiedMEMBER NUMBER
ILK23847Medicare ID - Type UnspecifiedMEMBER NUMBER
ILK23846Medicare ID - Type UnspecifiedMEMBER NUMBER