Provider Demographics
NPI:1275500100
Name:GRIMM, ELLEN M (MD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:M
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 1:12221 N MOPAC EXPY
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-2401
Mailing Address - Country:US
Mailing Address - Phone:512-805-0680
Mailing Address - Fax:512-805-0682
Practice Address - Street 1:1330 WONDER WORLD DR
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-7566
Practice Address - Country:US
Practice Address - Phone:512-805-0680
Practice Address - Fax:512-805-0682
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4170207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX101802002Medicaid
TX390007009OtherRAILROAD MEDICARE
TX101802004Medicaid
TX101802004Medicaid
TX8L20746Medicare PIN
TX390007009Medicare PIN