Provider Demographics
NPI:1407806748
Name:GRIMM, MATTHEW R (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:R
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 1:920 AVENUE B
Mailing Address - Street 2:
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-3112
Mailing Address - Country:US
Mailing Address - Phone:504-349-6804
Mailing Address - Fax:504-349-6844
Practice Address - Street 1:920 AVENUE B
Practice Address - Street 2:
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-3112
Practice Address - Country:US
Practice Address - Phone:504-349-6804
Practice Address - Fax:504-349-6844
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA021247207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5B353OtherMEDICARE GROUP
LA1792217OtherMEDICAID GROUP
LA200023859OtherRR MEDICARE INDIVIDUAL
LACK4990OtherRAILROAD MEDICARE GROUP
LA1974391Medicaid
LACK4990OtherRAILROAD MEDICARE GROUP
LA0418960001Medicare NSC
LA200023859OtherRR MEDICARE INDIVIDUAL