Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208000000X | Pediatrician | MT215614 | PA |
N | 2080P0208X | Pediatric Infectious Diseases | MT215614 | PA |
NPI | 1568955664 |
---|---|
Provider Name | Dr. Logan Phillip Grimes |
First Address | Philadelphia, PA 19104-4319 |
Second Address | Philadelphia, PA 19104-4319 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/06/2018 |
Last Update Date | 22/06/2021 |