Basic Information
| Provider Information | |||||||||
| NPI: | 1376565788 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRANT | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 320 E HIGHWAY 50 | ||||||||
| Address2: | |||||||||
| City: | O FALLON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622692704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186243368 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 HEALTH CENTER DRIVE | ||||||||
| Address2: | |||||||||
| City: | MATTOON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619380372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172582551 | ||||||||
| FaxNumber: | 2172582256 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2006 | ||||||||
| LastUpdateDate: | 03/02/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 2001022239 | MO | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.