Basic Information
| Provider Information | |||||||||
| NPI: | 1598877805 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRIMM | ||||||||
| FirstName: | LEANDER | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 405827 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303845827 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 401 SOUTHCREST CIRCLE | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | SOUTHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 38671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623490311 | ||||||||
| FaxNumber: | 6623490121 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 10/20/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 12705 | MS | Y | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 20507 | TN | N | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 3726800 | 05 | TN | MEDICAID | 00111800 | 05 | MS | MEDICAID | 4091934 | 01 | TN | BCBS TN PROVIDER NUMBER | OTHER |