Provider Demographics
NPI:1083702203
Name:JEFFREY S. GRANT, M.D., P.C.
Entity Type:Organization
Organization Name:JEFFREY S. GRANT, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:S
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-325-0072
Mailing Address - Street 1:PO BOX 677
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87499-0677
Mailing Address - Country:US
Mailing Address - Phone:505-325-0072
Mailing Address - Fax:505-327-1739
Practice Address - Street 1:608 E COMANCHE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-6815
Practice Address - Country:US
Practice Address - Phone:505-325-0072
Practice Address - Fax:505-327-1739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2011-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM99-216208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMA5179Medicaid
NMA5179Medicaid
343420400Medicare ID - Type Unspecified