Provider Demographics
NPI:1053549964
Name:GRIMES, MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:GRIMES
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 1:1900 WATERDAM PLAZA DR STE 2
Mailing Address - Street 2:
Mailing Address - City:CANONSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15317-5442
Mailing Address - Country:US
Mailing Address - Phone:724-941-7490
Mailing Address - Fax:724-941-5231
Practice Address - Street 1:1900 WATERDAM PLAZA DR STE 2
Practice Address - Street 2:
Practice Address - City:CANONSBURG
Practice Address - State:PA
Practice Address - Zip Code:15317-5442
Practice Address - Country:US
Practice Address - Phone:724-941-7490
Practice Address - Fax:724-941-5231
Is Sole Proprietor?:No
Enumeration Date:2009-06-30
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD450700207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1029321210001Medicaid
PA1029321210001Medicaid