Provider Demographics
NPI:1649241480
Name:GRIMALDI, MANUEL (MD)
Entity Type:Individual
Prefix:
First Name:MANUEL
Middle Name:
Last Name:GRIMALDI
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 1:4003 KRESGE WAY
Mailing Address - Street 2:SUITE 500
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207
Mailing Address - Country:US
Mailing Address - Phone:502-897-1166
Mailing Address - Fax:502-897-1461
Practice Address - Street 1:4003 KRESGE WAY
Practice Address - Street 2:SUITE 500
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207
Practice Address - Country:US
Practice Address - Phone:502-897-1166
Practice Address - Fax:502-897-1461
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY17866207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64178668Medicaid
C73926Medicare UPIN
KY64178668Medicaid