MEDICARE: DR. BRENT ALAN GRIMES NP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	16792	TN
2	363LF0000X	Family Nurse Practitioner	APN0000016792	TN
3	363L00000X	Nurse Practitioner	810467	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1578561262
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRENT ALAN GRIMES NP-C

Provider Business Mailing Address
First Line	:	PO BOX 1740
Second Line	:
City	:	CORINTH
State	:	MS
Zip	:	38835-1740
Country	:	US
Telephone Number	:	662-284-8565
Fax Number	:	662-594-8366

Provider Business Practice Location Address
First Line	:	3037 CORDER DR
Second Line	:
City	:	CORINTH
State	:	MS
Zip	:	38834-6216
Country	:	US
Telephone Number	:	662-284-8565
Fax Number	:	662-594-8366

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	06/27/2023

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