Provider Demographics
NPI:1407929565
Name:GRIMM, JAMES
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:GRIMM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1926 POTTER ST
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97405-3060
Mailing Address - Country:US
Mailing Address - Phone:541-357-8007
Mailing Address - Fax:888-541-9007
Practice Address - Street 1:1926 POTTER ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97405-3060
Practice Address - Country:US
Practice Address - Phone:541-221-9007
Practice Address - Fax:888-541-9007
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2009-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR191332084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR130703Medicaid
OR130703Medicaid