Provider Demographics
NPI:1982694717
Name:GRANT, MICHAEL THOMAS (M D)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:THOMAS
Last Name:GRANT
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 ORCHARD PARK RD
Mailing Address - Street 2:BUILDING B, SUITE 105
Mailing Address - City:WEST SENECA
Mailing Address - State:NY
Mailing Address - Zip Code:14224-2646
Mailing Address - Country:US
Mailing Address - Phone:716-677-6404
Mailing Address - Fax:716-677-6407
Practice Address - Street 1:550 ORCHARD PARK RD
Practice Address - Street 2:BUILDING B, SUITE 105
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224-2646
Practice Address - Country:US
Practice Address - Phone:716-677-6404
Practice Address - Fax:716-677-6407
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-24
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY147528174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00886879Medicaid
NYBB1860OtherMEDICARE
NY00010067501OtherUNIVERA
NY0902816OtherINDEPENDENT HEALTH
AA0091OtherMEDICARE LEGACY #
NY000500843001OtherBLUE CROSS
NY00886879Medicaid