Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RP1001X | Pulmonary Disease | 103150 | MO |
NPI | 1003967696 |
---|---|
Provider Name | Dr. Mark H. Grimm |
First Address | Springfield, MO 65801-2580 |
Second Address | Springfield, MO 65807-7304 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/01/2007 |
Last Update Date | 13/05/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
206653412 | (05) | MO |
E03582 | (02) | MO |