Healthcare Provider Details

I. General information

NPI: 1730175415
Provider Name (Legal Business Name): STEPHEN NELSON GRIMES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2005
Last Update Date: 04/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

566 TOLL GATE RD
WARWICK RI
02886-2716
US

IV. Provider business mailing address

566 TOLLGATE ROAD
WARWICK RI
02886-2716
US

V. Phone/Fax

Practice location:
  • Phone: 401-738-4800
  • Fax: 401-738-0174
Mailing address:
  • Phone: 401-738-4800
  • Fax: 401-738-0174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD04824
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: