Provider Demographics
NPI:1528040417
Name:MOORE, GRANT K (MD)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:K
Last Name:MOORE
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 1:100 WASON AVENUE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01107
Mailing Address - Country:US
Mailing Address - Phone:413-732-7426
Mailing Address - Fax:413-734-2371
Practice Address - Street 1:100 WASON AVENUE
Practice Address - Street 2:SUITE 100
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107
Practice Address - Country:US
Practice Address - Phone:413-732-7426
Practice Address - Fax:413-734-2371
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2372051207Y00000X
MA72182207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02668239Medicaid
MA3065898Medicaid
J09929Medicare ID - Type Unspecified
MA3065898Medicaid
NYRA7622Medicare ID - Type Unspecified