Provider Demographics
NPI:1306032297
Name:PETER GRANT, MD, LTD
Entity Type:Organization
Organization Name:PETER GRANT, MD, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-524-1747
Mailing Address - Street 1:1131 LAKE ST
Mailing Address - Street 2:#214
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301-1001
Mailing Address - Country:US
Mailing Address - Phone:708-524-1747
Mailing Address - Fax:
Practice Address - Street 1:1011 LAKE ST
Practice Address - Street 2:SUITE 300
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1148
Practice Address - Country:US
Practice Address - Phone:708-524-1747
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-24
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036108911261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL03610891106Medicaid
IL03610891106Medicaid
IL210249Medicare PIN