Provider Demographics
NPI:1154312841
Name:GRIMM, RUBY ANN (MD)
Entity Type:Individual
Prefix:
First Name:RUBY
Middle Name:ANN
Last Name:GRIMM
Suffix:
Gender:F
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:PO BOX 896199
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28289-6199
Mailing Address - Country:US
Mailing Address - Phone:704-873-2219
Mailing Address - Fax:704-873-1379
Practice Address - Street 1:738 BRYANT ST
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-4189
Practice Address - Country:US
Practice Address - Phone:704-873-2219
Practice Address - Fax:704-873-1379
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC21472173000000X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8937657Medicaid
NCC81211Medicare UPIN
NC2344740Medicare ID - Type Unspecified