Provider Demographics
NPI:1447282116
Name:GRIM, TRACEY P (MD)
Entity type:Individual
Prefix:DR
First Name:TRACEY
Middle Name:P
Last Name:GRIM
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 1:777 LOWNDES HILL RD BLDG 1
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-2101
Mailing Address - Country:US
Mailing Address - Phone:800-967-2289
Mailing Address - Fax:855-621-7065
Practice Address - Street 1:100 WELLNESS WAY
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:DE
Practice Address - Zip Code:19963-4364
Practice Address - Country:US
Practice Address - Phone:302-422-3311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD044957E207V00000X
DEC1-0011097207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1142786OtherAMERIHEALTHMERCY- WMG
PA5272418OtherAETNA
PA80744OtherUNISON- WMG
PA02016202OtherCAPITAL BLUE CROSS-WMG
PA1506605OtherGATEWAY- WMG
PA348539OtherMAMSI-ALLIANCE - WMG
MD524956OtherCAREFIRST MD BCBS
PA001250840Medicaid
PA32662OtherJOHNS HOPKINS
PA39193OtherGEISINGER HEALTH PLAN
PA662061OtherHIGHMARK BLUE SHIELD
PA5272418OtherAETNA
PA02016202OtherCAPITAL BLUE CROSS-WMG
PA80744OtherUNISON- WMG
PAE77805Medicare UPIN