MEDICARE: KENNETH J GRIMM MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	4301064321	MI

General Provider Information

NPI Number	:	1215916101
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH J GRIMM MD

Provider Business Mailing Address
First Line	:	49796 TAFT LN
Second Line	:
City	:	CANTON
State	:	MI
Zip	:	48188-6722
Country	:	US
Telephone Number	:	734-446-0310
Fax Number	:

Provider Business Practice Location Address
First Line	:	50439 INDEPENDENCE ST
Second Line	:
City	:	CANTON
State	:	MI
Zip	:	48188-6735
Country	:	US
Telephone Number	:	734-879-1068
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/10/2006
Last Update Date	:	01/06/2012

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