Provider Demographics
NPI:1942271689
Name:GRIMM, MARK W (MD)
Entity Type:Individual
Prefix:
First Name:MARK
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 790379
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63179-0379
Mailing Address - Country:US
Mailing Address - Phone:314-965-9184
Mailing Address - Fax:
Practice Address - Street 1:1011 BOWLES AVE
Practice Address - Street 2:SUITE 405
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-2395
Practice Address - Country:US
Practice Address - Phone:314-965-9184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001018662207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO011013883Medicare PIN
MOG86768Medicare UPIN