Healthcare Provider Details

I. General information

NPI: 1336122175
Provider Name (Legal Business Name): MICHAEL G GRIMES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2005
Last Update Date: 07/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4774 MUNSON ST NW SUITE 401
CANTON OH
44718-3634
US

IV. Provider business mailing address

270 EAST STATE STREET SUITE 240
ALLIANCE OH
44601-3634
US

V. Phone/Fax

Practice location:
  • Phone: 330-754-4431
  • Fax: 330-777-5499
Mailing address:
  • Phone: 330-596-6560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35077014G
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: