Provider Demographics
NPI:1891877742
Name:GRIMM, BENNETT DOUGLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:BENNETT
Middle Name:DOUGLAS
Last Name:GRIMM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 WHITCHER ST NE
Mailing Address - Street 2:SUITE 1100
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1176
Mailing Address - Country:US
Mailing Address - Phone:770-422-3290
Mailing Address - Fax:770-422-0287
Practice Address - Street 1:61 WHITCHER ST NE
Practice Address - Street 2:SUITE 1100
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1176
Practice Address - Country:US
Practice Address - Phone:770-422-3290
Practice Address - Fax:770-422-0287
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2012-00860207X00000X
GA068525207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003136592AMedicaid
GA003136592CMedicaid
GA003136592BMedicaid
GA202I201282Medicare PIN