Provider Demographics
NPI:1972502466
Name:SKIDMORE, GRANT ALAN (MD)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:ALAN
Last Name:SKIDMORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:300 MEDICAL PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-4985
Mailing Address - Country:US
Mailing Address - Phone:757-625-4455
Mailing Address - Fax:757-625-1829
Practice Address - Street 1:300 MEDICAL PKWY STE 200
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-4985
Practice Address - Country:US
Practice Address - Phone:757-625-4455
Practice Address - Fax:757-625-1829
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101052264207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA140004458OtherRAILROAD MEDICARE
VA006102441Medicaid
NC0569JOtherBCBS OF NORTH CAROLINA
VA076448OtherANTHEM BLUE CROSS BLUE SH
15591OtherSENTARA HEALTH PLAN
229060OtherMDIPA/MAMSI
4668815OtherAETNA HEALTH PLAN
149158900OtherUS DEPT OF LABOR
NC790569JOtherMEDICAID OF NORTH CAROLIN
VA140000145Medicare ID - Type Unspecified
4668815OtherAETNA HEALTH PLAN