Provider Demographics
NPI:1265692917
Name:GRANT, MICHAEL JOHN (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
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 1:4297 W PINE CLIFF CT
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99208-6929
Mailing Address - Country:US
Mailing Address - Phone:541-382-6633
Mailing Address - Fax:541-382-2719
Practice Address - Street 1:11995 SINGLETREE LN STE 500
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-5349
Practice Address - Country:US
Practice Address - Phone:952-595-1301
Practice Address - Fax:612-294-4903
Is Sole Proprietor?:No
Enumeration Date:2008-06-16
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD2071342085R0202X
WAMD605583922085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2026413Medicaid
WAG8960123Medicare PIN
WAG8944115Medicare PIN
WA2026413Medicaid
WAG8960122Medicare PIN
WAG8960120Medicare PIN
WAP01782603Medicare PIN