Healthcare Provider Details

I. General information

NPI: 1194790881
Provider Name (Legal Business Name): JEFFERY ROBERT GRIMES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 02/24/2025
Certification Date: 02/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 BEE ST
CHARLESTON SC
29401-5703
US

IV. Provider business mailing address

3725 SEABROOK ISLAND RD
JOHNS ISLAND SC
29455-6055
US

V. Phone/Fax

Practice location:
  • Phone: 843-577-5011
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number38962
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number38962
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number38962
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD29477
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: