Basic Information
| Provider Information | |||||||||
| NPI: | 1275500100 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRIMM | ||||||||
| FirstName: | ELLEN | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12221 N MOPAC EXPY | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787582401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5128050680 | ||||||||
| FaxNumber: | 5128050682 | ||||||||
| Practice Location | |||||||||
| Address1: | 1330 WONDER WORLD DR | ||||||||
| Address2: | |||||||||
| City: | SAN MARCOS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786667566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5128050680 | ||||||||
| FaxNumber: | 5128050682 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2006 | ||||||||
| LastUpdateDate: | 02/01/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | J4170 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 101802002 | 05 | TX | MEDICAID | 390007009 | 01 | TX | RAILROAD MEDICARE | OTHER | 101802004 | 05 | TX | MEDICAID |