Healthcare Provider Details

I. General information

NPI: 1245492586
Provider Name (Legal Business Name): MARY ELEANOR GRIMM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2008
Last Update Date: 06/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5035 E SAINT ANDREWS DR
TUCSON AZ
85718-1712
US

IV. Provider business mailing address

5035 E SAINT ANDREWS DR
TUCSON AZ
85718-1712
US

V. Phone/Fax

Practice location:
  • Phone: 520-299-6711
  • Fax: 520-299-6711
Mailing address:
  • Phone: 520-299-6711
  • Fax: 520-299-6711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number10277
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: