Provider Demographics
NPI:1497072532
Name:GRIMM, RYAN TIMOTHY (MD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:TIMOTHY
Last Name:GRIMM
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 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1818 CAREW ST STE 320
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4764
Practice Address - Country:US
Practice Address - Phone:260-373-5890
Practice Address - Fax:260-422-8444
Is Sole Proprietor?:No
Enumeration Date:2010-04-29
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01071541A208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201095340Medicaid
IN266180236Medicare PIN