Basic Information
| Provider Information | |||||||||
| NPI: | 1598276057 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRIMM | ||||||||
| FirstName: | TAYLORE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6522 ORANGE PLANK DR | ||||||||
| Address2: | |||||||||
| City: | HIXSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373433394 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2195751011 | ||||||||
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| Practice Location | |||||||||
| Address1: | 979 E 3RD ST STE C-520 | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374032136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237785661 | ||||||||
| FaxNumber: | 4237785664 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2017 | ||||||||
| LastUpdateDate: | 06/16/2018 | ||||||||
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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 | 208G00000X | 3397 | TN | N | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 363AS0400X | 3397 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 3397 | 01 | TN | STATE LICENSE NUMBER | OTHER |