Provider Demographics
NPI:1518149012
Name:GRANT INTERNAL MEDICINE PC
Entity Type:Organization
Organization Name:GRANT INTERNAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-362-9041
Mailing Address - Street 1:2908 FOOTHILL BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-4956
Mailing Address - Country:US
Mailing Address - Phone:307-362-9041
Mailing Address - Fax:307-362-9461
Practice Address - Street 1:2908 FOOTHILL BLVD STE B
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-4956
Practice Address - Country:US
Practice Address - Phone:307-362-9041
Practice Address - Fax:307-362-9461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-27
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6367A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty