Provider Demographics
NPI:1245345230
Name:GRIMM, SUZANNE B (MD)
Entity type:Individual
Prefix:DR
First Name:SUZANNE
Middle Name:B
Last Name:GRIMM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUZANNE
Other - Middle Name:BETH
Other - Last Name:GRIMM
Other - Suffix:
Other - Last Name Type:Doing Business As
Other - Credentials:
Mailing Address - Street 1:111 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-2571
Mailing Address - Country:US
Mailing Address - Phone:262-338-2717
Mailing Address - Fax:
Practice Address - Street 1:2414 KOHLER MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081
Practice Address - Country:US
Practice Address - Phone:920-457-4461
Practice Address - Fax:920-459-1139
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI382382084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32263500Medicaid
BG3570733OtherDEA NUMBER
WI32263500Medicaid
F36848Medicare UPIN