Provider Demographics
NPI:1700857125
Name:GRANT, MARC B (DO)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:B
Last Name:GRANT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:708 S COEUR D ALENE LN
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85541-5662
Mailing Address - Country:US
Mailing Address - Phone:928-468-1337
Mailing Address - Fax:928-468-1339
Practice Address - Street 1:708 S COEUR D ALENE LN
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:AZ
Practice Address - Zip Code:85541-5662
Practice Address - Country:US
Practice Address - Phone:928-468-1337
Practice Address - Fax:928-468-1339
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2012-09-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ1609207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZH20777190OtherBXBS
AZ285280Medicaid
AZZ141788Medicare PIN
AZ285280Medicaid