Provider Demographics
NPI:1194790881
Name:GRIMES, JEFFERY ROBERT
Entity type:Individual
Prefix:
First Name:JEFFERY
Middle Name:ROBERT
Last Name:GRIMES
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3725 SEABROOK ISLAND RD
Mailing Address - Street 2:
Mailing Address - City:JOHNS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29455-6055
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:109 BEE ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29401-5703
Practice Address - Country:US
Practice Address - Phone:843-577-5011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC38962207RA0401X, 207RG0300X, 207R00000X
SCMD29477207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC37653OtherBCBS
NC1194790881Medicaid
NC37653OtherBCBS
B05675Medicare UPIN