Healthcare Provider Details

I. General information

NPI: 1811048812
Provider Name (Legal Business Name): ANTHONY M GRIMALDI DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 12/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20201 CRAWFORD AVE SUITE 1276
OLYMPIA FIELDS IL
60461-1010
US

IV. Provider business mailing address

1040 SIERRA DR SUITE 400
GREENWOOD IN
46143-7240
US

V. Phone/Fax

Practice location:
  • Phone: 708-679-2270
  • Fax: 708-679-2272
Mailing address:
  • Phone: 317-528-4253
  • Fax: 317-865-8319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number036053826
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: