Basic Information
| Provider Information | |||||||||
| NPI: | 1558389106 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRIMM | ||||||||
| FirstName: | CAROL | ||||||||
| MiddleName: | JEAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 BROADWAY N | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581023641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012342397 | ||||||||
| FaxNumber: | 7012343861 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 BROADWAY N | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581023641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012344811 | ||||||||
| FaxNumber: | 7012346979 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 01/19/2012 | ||||||||
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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 | 207RX0202X | 5501 | ND | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 680387300 | 05 | MN | MEDICAID | 15677 | 05 | ND | MEDICAID |