Healthcare Provider Details

I. General information

NPI: 1679112072
Provider Name (Legal Business Name): BRIDGET GRIMES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2020
Last Update Date: 01/02/2020
Certification Date: 01/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8560 26TH AVE
KENOSHA WI
53143-6447
US

IV. Provider business mailing address

8527 N 60TH ST
BROWN DEER WI
53223-2801
US

V. Phone/Fax

Practice location:
  • Phone: 920-207-7904
  • Fax:
Mailing address:
  • Phone: 920-207-7904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number2166-39
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: