Basic Information
| Provider Information | |||||||||
| NPI: | 1194790881 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRIMES | ||||||||
| FirstName: | JEFFERY | ||||||||
| MiddleName: | ROBERT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3725 SEABROOK ISLAND RD | ||||||||
| Address2: | |||||||||
| City: | JOHNS ISLAND | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294556055 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 109 BEE ST | ||||||||
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| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294015703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435775011 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2006 | ||||||||
| LastUpdateDate: | 12/05/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RA0401X | 38962 | NC | N | Allopathic & Osteopathic Physicians | Internal Medicine | Addiction Medicine | 207RG0300X | 38962 | NC | N | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207R00000X | 38962 | NC | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | MD29477 | SC | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 37653 | 01 | NC | BCBS | OTHER | 1194790881 | 05 | NC | MEDICAID |