Provider Demographics
NPI:1235666298
Name:MOODY, GRANT HERRON (MD)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:HERRON
Last Name:MOODY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:450 NORTHSIDE CHEROKEE BLVD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30115-8015
Mailing Address - Country:US
Mailing Address - Phone:770-224-1000
Mailing Address - Fax:770-224-2451
Practice Address - Street 1:450 NORTHSIDE CHEROKEE BLVD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30115-8015
Practice Address - Country:US
Practice Address - Phone:770-224-1000
Practice Address - Fax:770-224-2451
Is Sole Proprietor?:No
Enumeration Date:2017-05-21
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL38192208M00000X
GA95843208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist