Healthcare Provider Details

I. General information

NPI: 1063618783
Provider Name (Legal Business Name): KRISTIN A GRIMES MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2007
Last Update Date: 03/07/2023
Certification Date: 02/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 NATE WHIPPLE HWY STE 102
CUMBERLAND RI
02864-1422
US

IV. Provider business mailing address

175 NATE WHIPPLE HWY STE 102
CUMBERLAND RI
02864-1422
US

V. Phone/Fax

Practice location:
  • Phone: 401-334-5437
  • Fax: 401-334-3571
Mailing address:
  • Phone: 401-334-5437
  • Fax: 401-334-3571

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD12296
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberMD12296
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: