Healthcare Provider Details

I. General information

NPI: 1588635361
Provider Name (Legal Business Name): RUSSELL SCOTT GRIMES D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 07/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 W SAINT MAARTENS DR STE A
SAINT JOSEPH MO
64506-2989
US

IV. Provider business mailing address

1005 W SAINT MAARTENS DR STE A
SAINT JOSEPH MO
64506-2989
US

V. Phone/Fax

Practice location:
  • Phone: 816-364-2338
  • Fax: 816-364-1003
Mailing address:
  • Phone: 816-364-2338
  • Fax: 816-364-1003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number2006000709
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: