Provider Demographics
NPI:1427022169
Name:GRANT, THOMAS RUSSELL (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:RUSSELL
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:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23501-0936
Mailing Address - Country:US
Mailing Address - Phone:757-446-5955
Mailing Address - Fax:757-446-5196
Practice Address - Street 1:825 FAIRFAX AVE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1914
Practice Address - Country:US
Practice Address - Phone:757-446-5955
Practice Address - Fax:757-446-5196
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101036347207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAPAROtherVIRGINIA PREMIER HEALTH
VA005612632Medicaid
NC0526KOtherBC/BS
VA081925OtherANTHEM
VAPAROtherMULTIPLAN
VA11025OtherSENTARA OPTIMA
NC890526KMedicaid
VAPAROtherCORVEL/CORCARE
VA005624151Medicaid
VAPAROtherVA HEALTH NETWORK
VAPAROtherFIRST HEATLH COMMERCIAL/SOUTHERN HEALTH/COVENTRY
VA-002 -003OtherTRICARE/CHAMPUS
VA2180424OtherUHC/MAMSI
VAPAROtherCIGNA
VAPAROtherAETNA
VAPAROtherUSA MANAGED CARE
VA080062017Medicare PIN
VA-002 -003OtherTRICARE/CHAMPUS
NC890526KMedicaid