Provider Demographics
NPI:1437356326
Name:GRANTHAM, BRIAN W (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:W
Last Name:GRANTHAM
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 8710
Mailing Address - Street 2:
Mailing Address - City:SPRINDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72766-8710
Mailing Address - Country:US
Mailing Address - Phone:479-521-0263
Mailing Address - Fax:
Practice Address - Street 1:509 E MAPLE AVE
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-5539
Practice Address - Country:US
Practice Address - Phone:479-521-0263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE998207P00000X, 207Q00000X, 207QG0300X, 207QS0010X, 2083S0010X, 208D00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR390200000XMedicare UPIN