Provider Demographics
NPI:1194752618
Name:GRIMM, TERRENCE E (MD)
Entity type:Individual
Prefix:
First Name:TERRENCE
Middle Name:E
Last Name:GRIMM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 BROADWAY N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-3641
Mailing Address - Country:US
Mailing Address - Phone:701-234-2401
Mailing Address - Fax:701-234-7378
Practice Address - Street 1:801 BROADWAY N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-3641
Practice Address - Country:US
Practice Address - Phone:701-234-2401
Practice Address - Fax:701-234-7378
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND5243207ZP0102X
MN29858207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
HP10513OtherHEALTHPARTNERS
10444OtherNDBC
ND16654Medicaid
1119587OtherMEDICA
MN924507300Medicaid
89611OtherPREFERRED ONE
92456GROtherMNBC
92456GROtherMNBC
NDN10444Medicare ID - Type Unspecified