Provider Demographics
NPI:1033557459
Name:GRANT, COURTNEY L (MD)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:L
Last Name:GRANT
Suffix:
Gender:F
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 742616
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2616
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:725 JESSE JEWELL PKWY SE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3834
Practice Address - Country:US
Practice Address - Phone:678-207-4000
Practice Address - Fax:770-531-2435
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-07
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116025753208600000X
GA86237208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003235364GMedicaid
GA003235364DMedicaid
GA003235364BMedicaid
GA003235364CMedicaid
GA003235364FMedicaid
GA003235364HMedicaid
GA003235364AMedicaid
GA003235364EMedicaid