Provider Demographics
NPI:1033214697
Name:GRANT, LYLE 'SCOTT' (MD)
Entity Type:Individual
Prefix:DR
First Name:LYLE
Middle Name:'SCOTT'
Last Name:GRANT
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:PO BOX 1361
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48012-1361
Mailing Address - Country:US
Mailing Address - Phone:248-645-1000
Mailing Address - Fax:248-645-0066
Practice Address - Street 1:180 E BROWN ST
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-6237
Practice Address - Country:US
Practice Address - Phone:248-645-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI059577207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine