Basic Information
| Provider Information | |||||||||
| NPI: | 1396841367 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRIMALDI | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2701 S. ROUSE | ||||||||
| Address2: | |||||||||
| City: | PITTSBURG | ||||||||
| State: | KS | ||||||||
| PostalCode: | 66762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6202320273 | ||||||||
| FaxNumber: | 6202317602 | ||||||||
| Practice Location | |||||||||
| Address1: | 2701 S. ROUSE | ||||||||
| Address2: | STE. A | ||||||||
| City: | PITTSBURG | ||||||||
| State: | KS | ||||||||
| PostalCode: | 66762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6202357605 | ||||||||
| FaxNumber: | 6202310081 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 02/13/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VX0000X | 04-16408 | KS | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Obstetrics | 207VX0000X | 0416408 | KS | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Obstetrics |
ID Information
| ID | Type | State | Issuer | Description | 100128140A | 05 | KS | MEDICAID |