Provider Demographics
NPI:1588827026
Name:GRIMES, JAISON A (MD)
Entity Type:Individual
Prefix:
First Name:JAISON
Middle Name:A
Last Name:GRIMES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:STE 130 - PROVIDER ENROLLMENT
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:355 W 16TH ST
Practice Address - Street 2:SUITE 3200
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2207
Practice Address - Country:US
Practice Address - Phone:317-963-7400
Practice Address - Fax:317-963-7425
Is Sole Proprietor?:No
Enumeration Date:2008-07-03
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01071593A2084N0400X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201109710Medicaid
IN201109710Medicaid
IN262210002Medicare PIN