Basic Information
| Provider Information | |||||||||
| NPI: | 1154315893 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRANT | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 7200 | ||||||||
| Address2: | |||||||||
| City: | ROCKY MOUNT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278040200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2529370200 | ||||||||
| FaxNumber: | 2524510056 | ||||||||
| Practice Location | |||||||||
| Address1: | 91 ENTERPRISE DR | ||||||||
| Address2: | |||||||||
| City: | ROCKY MOUNT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278049590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2524513100 | ||||||||
| FaxNumber: | 2529373106 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2005 | ||||||||
| LastUpdateDate: | 03/08/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0202X | 26825 | NC | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology | 208000000X | 26825 | NC | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1563457 | 01 | NC | CIGNA HEALTHCARE | OTHER | 259126 | 01 | NC | UNITED HEALTH CARE | OTHER | 7936770 | 05 | NC | MEDICAID | 36770 | 01 | NC | BCBSNC | OTHER | 370007244 | 01 | NC | RAILROAD MEDICARE | OTHER | 5541070 | 01 | NC | AETNA | OTHER | 66487 | 01 | NC | MEDCOST | OTHER |