Provider Demographics
NPI:1184837890
Name:DR RICHARD L GRANT P L C
Entity Type:Organization
Organization Name:DR RICHARD L GRANT P L C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:248-545-0100
Mailing Address - Street 1:581 FOX POINTE CT
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-1813
Mailing Address - Country:US
Mailing Address - Phone:248-334-9162
Mailing Address - Fax:248-334-2114
Practice Address - Street 1:27901 WOODWARD AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:BERKLEY
Practice Address - State:MI
Practice Address - Zip Code:48072-0919
Practice Address - Country:US
Practice Address - Phone:248-545-0100
Practice Address - Fax:248-545-1285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901000735213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4418408Medicaid
MI4856353590OtherBCBSM
MI4856353590OtherBCBSM
MI4418408Medicaid