Provider Demographics
NPI:1760404768
Name:GRIM, CLARENCE E (MD)
Entity Type:Individual
Prefix:MR
First Name:CLARENCE
Middle Name:E
Last Name:GRIM
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 1:195 HWY 50, SUITE #104
Mailing Address - Street 2:PMB 7172-289
Mailing Address - City:STATELINE
Mailing Address - State:NV
Mailing Address - Zip Code:89449-7172
Mailing Address - Country:US
Mailing Address - Phone:414-916-0841
Mailing Address - Fax:
Practice Address - Street 1:1180 N TOWN CENTER DR STE 100
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89144-6308
Practice Address - Country:US
Practice Address - Phone:414-916-0841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI36279207RE0101X, 207R00000X
NV14040207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32093400Medicaid
WI065E 73-601Medicare ID - Type UnspecifiedMILWAUKEE COUNTY
WI32093400Medicaid