Provider Demographics
NPI:1700894714
Name:ALLEN, GRANT R (MD)
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:R
Last Name:ALLEN
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 1:635 W COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35630-5313
Mailing Address - Country:US
Mailing Address - Phone:256-764-3431
Mailing Address - Fax:256-765-2036
Practice Address - Street 1:635 W COLLEGE ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35630-5313
Practice Address - Country:US
Practice Address - Phone:256-764-3431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2024-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL24600208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL513-05147OtherBCBS
AL318488Medicaid
AL317560Medicaid