Provider Demographics
NPI:1295809416
Name:RUBY ANN GRIMM
Entity type:Organization
Organization Name:RUBY ANN GRIMM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:L
Authorized Official - Last Name:SCIRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-873-2219
Mailing Address - Street 1:738 BRYANT STREET
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28677-4189
Mailing Address - Country:US
Mailing Address - Phone:704-873-2210
Mailing Address - Fax:704-873-1379
Practice Address - Street 1:738 BRYANT STREET
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-4189
Practice Address - Country:US
Practice Address - Phone:704-873-2219
Practice Address - Fax:704-873-1379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC21472207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8937657Medicaid
NC8937657Medicaid
NCC81211Medicare UPIN