Provider Demographics
NPI:1013479625
Name:GRANT, OLIVIA SHANEE (MD)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:SHANEE
Last Name:GRANT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7600 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:NORTH BERGEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07047-6217
Mailing Address - Country:US
Mailing Address - Phone:018-254-5100
Mailing Address - Fax:
Practice Address - Street 1:7600 RIVER RD
Practice Address - Street 2:
Practice Address - City:NORTH BERGEN
Practice Address - State:NJ
Practice Address - Zip Code:07047-6217
Practice Address - Country:US
Practice Address - Phone:201-854-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-02
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA11517200207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine