Healthcare Provider Details

I. General information

NPI: 1003906421
Provider Name (Legal Business Name): DAVID B GRIMM CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2006
Last Update Date: 11/15/2023
Certification Date: 11/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 BURLINGTON RD
JACKSON OH
45640-9360
US

IV. Provider business mailing address

500 BURLINGTON RD
JACKSON OH
45640-9360
US

V. Phone/Fax

Practice location:
  • Phone: 855-446-5937
  • Fax: 740-395-8519
Mailing address:
  • Phone: 855-446-5937
  • Fax: 740-395-8519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number42699
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCOA.01721-NA
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: