Provider Demographics
NPI:1396709499
Name:GRIMM, KATHLEEN T (MD)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:T
Last Name:GRIMM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3560 N BUFFALO ST
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-1934
Mailing Address - Country:US
Mailing Address - Phone:716-662-8510
Mailing Address - Fax:716-662-8574
Practice Address - Street 1:3560 N BUFFALO ST
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-1934
Practice Address - Country:US
Practice Address - Phone:716-662-8510
Practice Address - Fax:716-662-8574
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY198122207R00000X, 208000000X, 2080P0204X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01744283Medicaid
000524676004OtherBC/BS
080515000099OtherFIDELIS
00010298402OtherUNIVERA
NY000524676001OtherBC/BS OF WNY
000524676005OtherBC/BS
051213000027OtherFIDELIS
000524676003OtherBC/BS
0409065OtherIHA
05092300013OtherFIDELIS
NY00010298401OtherUNIVERA
NY00010298401OtherUNIVERA
000524676004OtherBC/BS
05092300013OtherFIDELIS
0409065OtherIHA