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General NPI Number Information
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NPI Number | 1194776344
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Entity Type | Individual
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Provider Name | JUDITH BYNUM GRIMM M.D.
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Gender | Female
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Dates
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Enumeration Date | 05/12/2006
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Last Update Date | 04/26/2018
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Provider Practice Location Address
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Address Line | 4600 ROGERS AVE
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City | FORT SMITH
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State | AR
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Zip | 72903-3149
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Country | US
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Telephone | 479-494-7443
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Fax |
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Provider Business Mailing Address
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Address Line | 464847 E 1098 RD
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City | SALLISAW
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State | OK
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Zip | 74955-5320
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Country | US
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Telephone | 318-794-9937
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | MD.14759R
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License Number State | LA
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | E-9002
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License Number State | AR
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