Provider Demographics
NPI:1417390881
Name:GRANT, BENJAMIN LAWRENCE
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:LAWRENCE
Last Name:GRANT
Suffix:
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 1:165 CHARLES RIVER PLAZA
Mailing Address - Street 2:SUITE 404
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114
Mailing Address - Country:US
Mailing Address - Phone:617-724-3909
Mailing Address - Fax:617-724-3944
Practice Address - Street 1:165 CHARLES RIVER PLAZA
Practice Address - Street 2:SUITE 404 OCCUPATIONAL HEALTH SERVICES
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-0000
Practice Address - Country:US
Practice Address - Phone:617-724-3909
Practice Address - Fax:617-724-3944
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-16
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN274235363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology