Basic Information
| Provider Information | |||||||||
| NPI: | 1811048812 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRIMALDI | ||||||||
| FirstName: | ANTHONY | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1040 SIERRA DR | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | GREENWOOD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461437240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175284253 | ||||||||
| FaxNumber: | 3178658319 | ||||||||
| Practice Location | |||||||||
| Address1: | 20201 CRAWFORD AVE | ||||||||
| Address2: | SUITE 1276 | ||||||||
| City: | OLYMPIA FIELDS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604611010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7086792270 | ||||||||
| FaxNumber: | 7086792272 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2007 | ||||||||
| LastUpdateDate: | 12/03/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 036053826 | IL | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | BLUE CROSS BLUE SHIE | 01 | IL | 21626252 | OTHER | 203979055 | 01 | IL | MEDICARE PTAN | OTHER |