Provider Demographics
NPI:1376565788
Name:GRANT, GEORGE R (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:R
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 1:320 E HIGHWAY 50
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-2704
Mailing Address - Country:US
Mailing Address - Phone:618-624-3368
Mailing Address - Fax:
Practice Address - Street 1:1000 HEALTH CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-0372
Practice Address - Country:US
Practice Address - Phone:217-258-2551
Practice Address - Fax:217-258-2256
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001022239207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOE90785Medicare UPIN
119050069Medicare ID - Type Unspecified