Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207R00000X | Internist | 38962 | NC |
N | 111NI0900X | Internist | 38962 | NC |
Y | 207R00000X | Internist | MD29477 | SC |
Y | 111NI0900X | Internist | MD29477 | SC |
N | 207RA0401X | Internist - Addiction Medicine | 38962 | NC |
N | 207RG0300X | Geriatric Medicine | 38962 | NC |
NPI | 1194790881 |
---|---|
Provider Name | Jeffery Robert Grimes |
First Address | Johns Island, SC 29455-6055 |
Second Address | Charleston, SC 29401-5703 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/02/2006 |
Last Update Date | 05/12/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1194790881 | (05) | NC |
37653 | BCBS (01) | NC |
B05675 | (02) |