Basic Information
| Provider Information | |||||||||
| NPI: | 1144260100 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRANT | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1775 W HIBISCUS BLVD | ||||||||
| Address2: | SUITE 215 | ||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329012620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218373820 | ||||||||
| FaxNumber: | 3218373654 | ||||||||
| Practice Location | |||||||||
| Address1: | 1775 W HIBISCUS BLVD | ||||||||
| Address2: | SUITE 215 | ||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329012620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218373820 | ||||||||
| FaxNumber: | 3218373654 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 05/17/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | ME86879 | FL | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 273546600 | 05 | FL | MEDICAID |