Provider Demographics
NPI:1851684336
Name:JEFFREY NATHAN GRANT,M.D. A MEDICAL CORP
Entity Type:Organization
Organization Name:JEFFREY NATHAN GRANT,M.D. A MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:JNATHAN
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-659-4511
Mailing Address - Street 1:8733 BEVERLY BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90048-1827
Mailing Address - Country:US
Mailing Address - Phone:310-659-4511
Mailing Address - Fax:310-659-1520
Practice Address - Street 1:8733 BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90048-1827
Practice Address - Country:US
Practice Address - Phone:310-659-4511
Practice Address - Fax:310-659-1520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-17
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA24260261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA24260Medicare UPIN