Provider Demographics
NPI:1801428313
Name:O'BRYAN, GRANT MATTHEW
Entity type:Individual
Prefix:MR
First Name:GRANT
Middle Name:MATTHEW
Last Name:O'BRYAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 W HIGHWAY 50
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1618
Mailing Address - Country:US
Mailing Address - Phone:618-624-4471
Mailing Address - Fax:618-624-4496
Practice Address - Street 1:3718 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62305-2822
Practice Address - Country:US
Practice Address - Phone:217-728-1505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-12
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3405237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist