Healthcare Provider Details

I. General information

NPI: 1093751224
Provider Name (Legal Business Name): JOHN D GRIMME MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 06/10/2022
Certification Date: 06/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 PRINCE WILLIAM PKWY STE 302
WOODBRIDGE VA
22192-7667
US

IV. Provider business mailing address

8001 FORBES PL STE 103
SPRINGFIELD VA
22151-2205
US

V. Phone/Fax

Practice location:
  • Phone: 703-494-3309
  • Fax: 703-321-3300
Mailing address:
  • Phone: 814-426-7319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number0101255768
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number25740
License Number StateWV
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD25664
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: