Provider Demographics
NPI:1881916427
Name:ROBERT CLYDE GRANT MD PC
Entity type:Organization
Organization Name:ROBERT CLYDE GRANT MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:CLYDE
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-536-1381
Mailing Address - Street 1:174 PRIOR ST SE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3447
Mailing Address - Country:US
Mailing Address - Phone:770-536-1381
Mailing Address - Fax:770-532-8721
Practice Address - Street 1:174 PRIOR ST SE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3447
Practice Address - Country:US
Practice Address - Phone:770-536-1381
Practice Address - Fax:770-532-8721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-24
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA8102261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000070815AMedicaid
GA000070815AMedicaid
GA108102070AMedicare UPIN