Provider Demographics
NPI:1700883691
Name:GRIMM, JOHN O (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:O
Last Name:GRIMM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 CROSSLAKE DR
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47715-8198
Mailing Address - Country:US
Mailing Address - Phone:812-477-1558
Mailing Address - Fax:
Practice Address - Street 1:225 CROSSLAKE DR
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-8198
Practice Address - Country:US
Practice Address - Phone:812-477-1558
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1037941207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN130960OtherHEALTHLINK
IN000000108308OtherANTHEM
IN130960OtherHEALTHLINK
IN000000108308OtherANTHEM