Provider Demographics
NPI:1326441213
Name:ANDERSON, GRANT SR
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:ANDERSON
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4353 KENTUCKY ST
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46409-2339
Mailing Address - Country:US
Mailing Address - Phone:219-677-7668
Mailing Address - Fax:
Practice Address - Street 1:4353 KENTUCKY ST
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46409-2339
Practice Address - Country:US
Practice Address - Phone:219-677-7668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-06
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0550-22-9431343800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343800000XTransportation ServicesSecured Medical Transport (VAN)