Provider Demographics
NPI:1427368471
Name:GRANT DISICK MD PA
Entity Type:Organization
Organization Name:GRANT DISICK MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:I
Authorized Official - Last Name:DISICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-487-5506
Mailing Address - Street 1:9970 CENTRAL PARK BLVD N
Mailing Address - Street 2:SUITE 207
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33428-2231
Mailing Address - Country:US
Mailing Address - Phone:561-487-5506
Mailing Address - Fax:561-487-9261
Practice Address - Street 1:9970 CENTRAL PARK BLVD N
Practice Address - Street 2:SUITE 207
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33428-2231
Practice Address - Country:US
Practice Address - Phone:561-487-5506
Practice Address - Fax:561-487-9261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-08
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME101748208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME101748OtherLICENSE
FL11763982OtherCAQH
FL11763982OtherCAQH