Healthcare Provider Details

I. General information

NPI: 1477643070
Provider Name (Legal Business Name): JOHANNES FREDRIK GRIMMER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 11/02/2021
Certification Date: 11/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N MEDICAL DR SUITE 4500
SALT LAKE CITY UT
84113-1103
US

IV. Provider business mailing address

PO BOX 581094
SALT LAKE CITY UT
84158-1094
US

V. Phone/Fax

Practice location:
  • Phone: 801-662-5671
  • Fax:
Mailing address:
  • Phone: 801-213-3800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number5856707-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: