Provider Demographics
NPI:1952618415
Name:GRANT MEDICAL SERVICE, INC
Entity Type:Organization
Organization Name:GRANT MEDICAL SERVICE, INC
Other - Org Name:GRANT MEDICAL SERVICE, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHAIRPERSON
Authorized Official - Prefix:
Authorized Official - First Name:YVONNE
Authorized Official - Middle Name:EVADNEY
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:863-398-8152
Mailing Address - Street 1:5337 N SOCRUM LOOP RD
Mailing Address - Street 2:SUITE 146
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33809-4256
Mailing Address - Country:US
Mailing Address - Phone:863-859-7355
Mailing Address - Fax:
Practice Address - Street 1:5337 N SOCRUM LOOP RD
Practice Address - Street 2:SUITE 146
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33809-4256
Practice Address - Country:US
Practice Address - Phone:863-859-7355
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-05
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1899642363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP71243Medicare UPIN