Provider Demographics
NPI:1952486920
Name:GRIMSLEY, EDWIN W (MD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:W
Last Name:GRIMSLEY
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 4947
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31208-4947
Mailing Address - Country:US
Mailing Address - Phone:478-301-4111
Mailing Address - Fax:478-301-2272
Practice Address - Street 1:707 PINE STREET
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201
Practice Address - Country:US
Practice Address - Phone:478-301-5801
Practice Address - Fax:478-301-5812
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA030468207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00034304CMedicaid
GAP00034286OtherRAILROAD MEDICARE
GAP00034286OtherRAILROAD MEDICARE
11BDWSCMedicare ID - Type Unspecified
GA00034304CMedicaid