Provider Demographics
NPI:1558389106
Name:GRIMM, CAROL JEAN (MD)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:JEAN
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 1:801 BROADWAY N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-3641
Mailing Address - Country:US
Mailing Address - Phone:701-234-2397
Mailing Address - Fax:701-234-3861
Practice Address - Street 1:801 BROADWAY N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-3641
Practice Address - Country:US
Practice Address - Phone:701-234-4811
Practice Address - Fax:701-234-6979
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND5501207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN680387300Medicaid
ND15677Medicaid
MN680387300Medicaid
NDN2833Medicare PIN