Healthcare Provider Details

I. General information

NPI: 1407929565
Provider Name (Legal Business Name): JAMES GRIMM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 10/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1926 POTTER ST
EUGENE OR
97405-3060
US

IV. Provider business mailing address

1926 POTTER ST
EUGENE OR
97405-3060
US

V. Phone/Fax

Practice location:
  • Phone: 541-221-9007
  • Fax: 888-541-9007
Mailing address:
  • Phone: 541-357-8007
  • Fax: 888-541-9007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number19133
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier130703
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: