Basic Information
| Provider Information | |||||||||
| NPI: | 1396815015 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRIMES | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | DANA | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GRIMES | ||||||||
| OtherFirstName: | MICHAEL | ||||||||
| OtherMiddleName: | DANA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2828 1ST AVE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257021236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045256905 | ||||||||
| FaxNumber: | 3045254316 | ||||||||
| Practice Location | |||||||||
| Address1: | 2828 1ST AVE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257021236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045256905 | ||||||||
| FaxNumber: | 3045254316 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2006 | ||||||||
| LastUpdateDate: | 02/21/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 905 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 381000527 | 05 | WV | MEDICAID | MG1289506 | 01 | WV | DEA NUMBER | OTHER | 905 | 01 | WV | STATE LICENSE | OTHER |