Provider Demographics
NPI:1659363687
Name:GRIMM, THOMAS W (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:W
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:PO BOX 637676
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-0001
Mailing Address - Country:US
Mailing Address - Phone:513-891-2211
Mailing Address - Fax:513-891-2218
Practice Address - Street 1:11029 MONTGOMERY RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45249-2306
Practice Address - Country:US
Practice Address - Phone:513-891-2211
Practice Address - Fax:513-891-2218
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35053367207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0638699Medicaid
OHD26884Medicare UPIN
OH0638699Medicaid