Basic Information
| Provider Information | |||||||||
| NPI: | 1700938610 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRIM | ||||||||
| FirstName: | TODD | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 FAIRMOUNT AVE | ||||||||
| Address2: | STE 302 | ||||||||
| City: | TOWSON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212865494 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109278768 | ||||||||
| FaxNumber: | 4106484878 | ||||||||
| Practice Location | |||||||||
| Address1: | 431 E RIDGEVILLE BLVD | ||||||||
| Address2: | |||||||||
| City: | MOUNT AIRY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217715217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018296811 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 03/15/2017 | ||||||||
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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 | 225100000X | 21685 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 2160584 | 01 | ACN | OTHER | 2160584 | 01 | UHC | OTHER | 7914198 | 01 | AETNA | OTHER | 917546-01 | 01 | BCBS OF MARYLAND | OTHER | T208 | 01 | BLUECHOICE/GHMSI | OTHER |