Provider Demographics
NPI:1083894125
Name:BRADLEY P GRANT MD PA
Entity type:Organization
Organization Name:BRADLEY P GRANT MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:P
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-724-2188
Mailing Address - Street 1:1480 S WICKHAM RD
Mailing Address - Street 2:
Mailing Address - City:W MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-2447
Mailing Address - Country:US
Mailing Address - Phone:321-724-2188
Mailing Address - Fax:321-724-2833
Practice Address - Street 1:1480 S WICKHAM RD
Practice Address - Street 2:
Practice Address - City:W MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-2447
Practice Address - Country:US
Practice Address - Phone:321-724-2188
Practice Address - Fax:321-724-2833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-06
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK8132Medicare PIN