Provider Demographics
NPI:1003906421
Name:GRIMM, DAVID B (CRNA)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:B
Last Name:GRIMM
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 BURLINGTON RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:OH
Mailing Address - Zip Code:45640-9360
Mailing Address - Country:US
Mailing Address - Phone:855-446-5937
Mailing Address - Fax:740-395-8519
Practice Address - Street 1:500 BURLINGTON RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:OH
Practice Address - Zip Code:45640-9360
Practice Address - Country:US
Practice Address - Phone:855-446-5937
Practice Address - Fax:740-395-8519
Is Sole Proprietor?:No
Enumeration Date:2006-10-14
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY42699367500000X
OHCOA.01721-NA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0752074Medicaid
WV0065977000Medicaid
WV0065977000Medicaid
OHH2279791Medicare PIN