Active NPI
Russell T Grimm, D.D.S.
- Dentist
- Madison, WI
National Provider Identifier
1508085481
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 5193-015
- Practice address
- 749 University Row
Madison, WI 53705 - Phone
- (608) 238-7112
- Fax
- (608) 238-1061
- NPI assigned
- Apr 25, 2007
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 5193-015 | WI | Primary |
| General Practice Dentistry | 1223G0001X | 5193 | WI |
Addresses
Primary practice location
749 University Row
Madison, WI 53705
Mailing address
749 University Row
Madison, WI 53705
Phone (608) 238-7112
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 33759600 | Medicaid | WI |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 5193-015 | WI | MD | Dentist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Associated Dentists | Dentist | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1177459200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1381190400000",
"number": "1508085481",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "749 UNIVERSITY ROW",
"city": "MADISON",
"state": "WI",
"postal_code": "53705",
"telephone_number": "608-238-7112",
"fax_number": "608-238-1061"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "749 UNIVERSITY ROW",
"city": "MADISON",
"state": "WI",
"postal_code": "53705",
"telephone_number": "608-238-7112",
"fax_number": "608-238-1061"
}
],
"practiceLocations": [],
"basic": {
"last_name": "GRIMM",
"first_name": "RUSSELL",
"middle_name": "T",
"name_prefix": "Dr.",
"credential": "D.D.S.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2007-04-25",
"last_updated": "2013-10-08",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "WI",
"license": "5193-015",
"primary": true
},
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "WI",
"license": "5193",
"primary": false
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "33759600",
"state": "WI"
}
],
"endpoints": [],
"other_names": []
}Other providers in Madison, WI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 8, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.