MEDICARE: DR. MARY ELEANOR 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	208000000X	Pediatrics Physician	10277	AZ

General Provider Information

NPI Number	:	1245492586
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY ELEANOR GRIMM MD

Provider Business Mailing Address
First Line	:	5035 E SAINT ANDREWS DR
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85718-1712
Country	:	US
Telephone Number	:	520-299-6711
Fax Number	:	520-299-6711

Provider Business Practice Location Address
First Line	:	5035 E SAINT ANDREWS DR
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85718-1712
Country	:	US
Telephone Number	:	520-299-6711
Fax Number	:	520-299-6711

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

Provider Enumeration Date	:	06/27/2008
Last Update Date	:	06/27/2008

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