Healthcare Provider Details

I. General information

NPI: 1598276057
Provider Name (Legal Business Name): TAYLORE MARIE GRIMM PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2017
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

979 E 3RD ST STE C-520
CHATTANOOGA TN
37403-2136
US

IV. Provider business mailing address

6522 ORANGE PLANK DR
HIXSON TN
37343-3394
US

V. Phone/Fax

Practice location:
  • Phone: 423-778-5661
  • Fax: 423-778-5664
Mailing address:
  • Phone: 219-575-1011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number3397
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number3397
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: