MEDICARE: DORIS ELAINE GRIMES CRNA

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	174400000X	Specialist	RN552231	PA
2	367500000X	Certified Registered Nurse Anesthetist	498642	NY

General Provider Information

NPI Number	:	1871597724
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DORIS ELAINE GRIMES CRNA

Provider Business Mailing Address
First Line	:	PO BOX 2005
Second Line	:
City	:	EAST SYRACUSE
State	:	NY
Zip	:	13057-4505
Country	:	US
Telephone Number	:	315-449-0513
Fax Number	:

Provider Business Practice Location Address
First Line	:	830 WASHINGTON ST
Second Line	:
City	:	WATERTOWN
State	:	NY
Zip	:	13601-4034
Country	:	US
Telephone Number	:	315-449-0513
Fax Number	:

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

Provider Enumeration Date	:	06/09/2005
Last Update Date	:	05/16/2020

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