Provider Demographics
NPI:1396841367
Name:GRIMALDI, GARY A (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:A
Last Name:GRIMALDI
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 1:2701 S. ROUSE
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:KS
Mailing Address - Zip Code:66762
Mailing Address - Country:US
Mailing Address - Phone:620-232-0273
Mailing Address - Fax:620-231-7602
Practice Address - Street 1:2701 S. ROUSE
Practice Address - Street 2:STE. A
Practice Address - City:PITTSBURG
Practice Address - State:KS
Practice Address - Zip Code:66762
Practice Address - Country:US
Practice Address - Phone:620-235-7605
Practice Address - Fax:620-231-0081
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-16408207VX0000X
KS0416408207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100128140AMedicaid
KS100128140AMedicaid
045056Medicare ID - Type Unspecified