Individual Professional Information |
|
NPI
|
1154303501
|
|
Unique healthcare provider (clinician) ID assigned by NPPES
|
|
PECOS UID
|
5799859526
|
|
Unique individual clinician ID assigned by PECOS
|
|
Professional Enrollment ID
|
I20200819002766
|
|
Unique ID for the individual professional enrollment that is the source for the data in the observation
|
|
Provider Last Name
|
GRIME
|
|
Individual professional last name
|
|
Provider First Name
|
TODD
|
|
Individual professional first name
|
|
Provider Middle Name
|
E
|
|
Individual professional middle name
|
|
Provider Gender
|
M
|
|
The provider's gender if the provider is a person.
|
Practice Information |
|
Organization Legal Name
|
BEACON ORTHOPAEDICS AND SPORTS MEDICINE LTD
|
|
Legal name of the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
|
|
Group Practice PAC ID
|
0345136412
|
|
Unique Group Practice ID assigned by PECOS to the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
|
|
Number of Group Practice members
|
101
|
|
Total number of individual professionals affiliated with the Group Practice based on Group Practice PAC ID
|
|
Line 1 Street Address
|
1360 E STATE RD
|
|
Group Practice or individual's line 1 address
|
|
Line 2 Street Address
|
SUITE 46
|
|
Group Practice or individual's line 2 address
|
|
City
|
BATESVILLE
|
|
Group Practice or individual's city
|
|
State
|
IN
|
|
Group Practice or individual's state
|
|
Zip Code
|
470069269
|
|
Group Practice or individual's zip code (9 digits when available)
|
|
Phone Number
|
5133543700
|
|
Phone number is listed only when there is a single phone number available for the practice location address
|