Provider Demographics
NPI:1255359287
Name:GRIMM, MATTHEW WILLIAM (PT)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:WILLIAM
Last Name:GRIMM
Suffix:
Gender:M
Credentials:PT
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-316-4443
Mailing Address - Fax:
Practice Address - Street 1:11840 SOUTHMORE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-4466
Practice Address - Country:US
Practice Address - Phone:704-316-4443
Practice Address - Fax:704-316-4444
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501012853225100000X
NCP14088225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650D116650OtherBCBS
MI1255359287OtherNPI
NCPENDINGMedicaid
NCPENDINGMedicare PIN
MIN81330006Medicare PIN