Provider Demographics
NPI:1407065709
Name:LEE GRIMM, MD PC
Entity Type:Organization
Organization Name:LEE GRIMM, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIMM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-854-0001
Mailing Address - Street 1:7580 CLARINGTON CV
Mailing Address - Street 2:SUITE 3
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-5657
Mailing Address - Country:US
Mailing Address - Phone:423-854-0001
Mailing Address - Fax:423-854-0002
Practice Address - Street 1:3101 BROWNS MILL RD PMB 386
Practice Address - Street 2:SUITE 6
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-4100
Practice Address - Country:US
Practice Address - Phone:423-854-0001
Practice Address - Fax:423-854-0002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD20507173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00111800Medicaid
TN3053456Medicaid
MS00111800Medicaid
TN3053456Medicaid