Provider Demographics
NPI:1720122286
Name:ORTHMEYER, GRANT KENNETH (MD)
Entity Type:Individual
Prefix:DR
First Name:GRANT
Middle Name:KENNETH
Last Name:ORTHMEYER
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 1:707 IRVING AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-2880
Mailing Address - Country:US
Mailing Address - Phone:248-546-4896
Mailing Address - Fax:
Practice Address - Street 1:6777 W MAPLE RD
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3013
Practice Address - Country:US
Practice Address - Phone:248-325-0300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-17
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1060299207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI10-4996608Medicaid
MI10-4996635Medicaid
MI10-4996448Medicaid
MI10-4996528Medicaid
MI10-4994130Medicaid
MI10-4996395Medicaid
MI10-4996475Medicaid
MI10-4996439Medicaid
MI10-4996466Medicaid
MI10-4994149Medicaid
MI10-4996564Medicaid
N87430053Medicare PIN
MI10-4996635Medicaid
P40540031Medicare PIN