Provider Demographics
NPI:1114000536
Name:RICHARD L GRANT MD PC
Entity Type:Organization
Organization Name:RICHARD L GRANT MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:LOCKE
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-692-5550
Mailing Address - Street 1:709 TOWNES COURT
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-1381
Mailing Address - Country:US
Mailing Address - Phone:309-692-5550
Mailing Address - Fax:309-692-5553
Practice Address - Street 1:7309 N KNOXVILLE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614
Practice Address - Country:US
Practice Address - Phone:309-692-5550
Practice Address - Fax:309-692-5553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2084F0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PIN204498Medicare ID - Type Unspecified
C42225Medicare UPIN