Provider Demographics
NPI:1316219546
Name:GRANT, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
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 1:225 N MICHIGAN AVE
Mailing Address - Street 2:BCBSA
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-7757
Mailing Address - Country:US
Mailing Address - Phone:312-297-6216
Mailing Address - Fax:
Practice Address - Street 1:225 N MICHIGAN AVE
Practice Address - Street 2:BCBSA
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-7757
Practice Address - Country:US
Practice Address - Phone:312-297-6216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-03
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036075647207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine