Provider Demographics
NPI:1962490128
Name:GRANT, BRYDON JB (MD)
Entity Type:Individual
Prefix:DR
First Name:BRYDON
Middle Name:JB
Last Name:GRANT
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 1:205 BAYNES CT
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27517-9523
Mailing Address - Country:US
Mailing Address - Phone:919-419-0125
Mailing Address - Fax:
Practice Address - Street 1:10712 S 1300 E
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-5094
Practice Address - Country:US
Practice Address - Phone:800-258-5329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-12
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5868721-1205207RS0012X
NY154772207RS0012X
NC207RS0012X, 207RP1001X
IL207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02506141Medicaid
NYC49465Medicare UPIN
NY02506141Medicaid