Basic Information
| Provider Information | |||||||||
| NPI: | 1194776344 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRIMM | ||||||||
| FirstName: | JUDITH | ||||||||
| MiddleName: | BYNUM | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NANCE | ||||||||
| OtherFirstName: | JUDITH | ||||||||
| OtherMiddleName: | BYNUM | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 464847 E 1098 RD | ||||||||
| Address2: | |||||||||
| City: | SALLISAW | ||||||||
| State: | OK | ||||||||
| PostalCode: | 749555320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3187949937 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4600 ROGERS AVE | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729033149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794947443 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 04/26/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD.14759R | LA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | E-9002 | AR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 030477389 | 01 | LA | HUMANA | OTHER | 030477389 | 01 | LA | BEST CARE NETWORK | OTHER | 030477389 | 01 | LA | UNITED HEALTHCARE | OTHER | 1438154 | 05 | LA | MEDICAID | 030477389 | 01 | LA | HUMANA MILITARY | OTHER |