Provider Demographics
NPI:1306853858
Name:GRANT, PETER JAMES (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:JAMES
Last Name:GRANT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 S MAPLE AVE
Mailing Address - Street 2:SUITE 3000
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60304-1091
Mailing Address - Country:US
Mailing Address - Phone:708-524-1747
Mailing Address - Fax:708-383-2741
Practice Address - Street 1:610 S MAPLE AVE
Practice Address - Street 2:SUITE 3000
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60304-1091
Practice Address - Country:US
Practice Address - Phone:708-524-1747
Practice Address - Fax:708-383-2741
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-108911207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-10891106Medicaid
IL036-10891106Medicaid
ILH96704Medicare UPIN