Healthcare Provider Details

I. General information

NPI: 1154318574
Provider Name (Legal Business Name): PATRICK J GRIMM PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 11/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 WESTWOOD DR
HAMILTON MT
59840-2345
US

IV. Provider business mailing address

1224 W MAIN ST
HAMILTON MT
59840-2338
US

V. Phone/Fax

Practice location:
  • Phone: 406-363-0597
  • Fax: 406-375-4858
Mailing address:
  • Phone: 406-375-4823
  • Fax: 406-375-4846

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number468
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number468
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: