Provider Demographics
NPI:1871540815
Name:GRIMM, BRIAN MICHAEL (MD)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:MICHAEL
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 1:520 W PALMDALE BLVD STE V
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93551-4231
Mailing Address - Country:US
Mailing Address - Phone:661-361-9380
Mailing Address - Fax:
Practice Address - Street 1:520 W PALMDALE BLVD STE V
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93551-4231
Practice Address - Country:US
Practice Address - Phone:661-361-9380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-27
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA91113207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA91113AMedicare ID - Type Unspecified
I03513Medicare UPIN