Healthcare Provider Details

I. General information

NPI: 1720281819
Provider Name (Legal Business Name): LEANDER MOREL GRIMM JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2007
Last Update Date: 07/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2451 FILLINGIM ST MASTIN BLDG. SUITE 101
MOBILE AL
36617-2238
US

IV. Provider business mailing address

PO BOX 40480
MOBILE AL
36640-0480
US

V. Phone/Fax

Practice location:
  • Phone: 251-445-8282
  • Fax: 251-445-8281
Mailing address:
  • Phone: 251-445-8282
  • Fax: 251-445-8281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number29334
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number29334
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: