Provider Demographics
NPI:1144211541
Name:GRIMBALL, EDWARD ALLAN (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:ALLAN
Last Name:GRIMBALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 BOGLE ST
Mailing Address - Street 2:STE 3
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-2870
Mailing Address - Country:US
Mailing Address - Phone:606-451-9953
Mailing Address - Fax:606-451-1533
Practice Address - Street 1:402 BOGLE ST
Practice Address - Street 2:STE 3
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-2870
Practice Address - Country:US
Practice Address - Phone:606-451-9953
Practice Address - Fax:606-451-1533
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY29702207R00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000075035OtherANTHEM
KY5169150OtherCCN/AETNA
KY37J8OtherANTHEM
KY1101698818OtherMEDICARE RAILROAD
KY1181211OtherCHA
KY611350780OtherFEDERAL TAX ID
KY04-906OtherUNITED HEALTHCARE
KY64297021Medicaid
KY37J8OtherANTHEM
KY1181211OtherCHA