Provider Demographics
NPI:1013987528
Name:GRIMM, KATHERINE TEETS (MD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:TEETS
Last Name:GRIMM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10044-0025
Mailing Address - Country:US
Mailing Address - Phone:212-753-5505
Mailing Address - Fax:212-753-5506
Practice Address - Street 1:501 MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10044-0025
Practice Address - Country:US
Practice Address - Phone:212-753-5505
Practice Address - Fax:212-753-5506
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY120015208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00225374Medicaid
NY00225374Medicaid