MEDICARE: DR. MARK STEVEN GRIMSLEY 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	41572	GA

General Provider Information

NPI Number	:	1861729816
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK STEVEN GRIMSLEY MD

Provider Business Mailing Address
First Line	:	1611 SATELLITE BLVD STE 3
Second Line	:
City	:	DULUTH
State	:	GA
Zip	:	30097-4913
Country	:	US
Telephone Number	:	770-614-6266
Fax Number	:

Provider Business Practice Location Address
First Line	:	1611 SATELLITE BLVD STE 3
Second Line	:
City	:	DULUTH
State	:	GA
Zip	:	30097
Country	:	US
Telephone Number	:	770-614-6266
Fax Number	:

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

Provider Enumeration Date	:	11/12/2009
Last Update Date	:	01/18/2019

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