Basic Information
| Provider Information | |||||||||
| NPI: | 1427022169 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRANT | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | RUSSELL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 936 | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235010936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574465955 | ||||||||
| FaxNumber: | 7574465196 | ||||||||
| Practice Location | |||||||||
| Address1: | 825 FAIRFAX AVE | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235071914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574465955 | ||||||||
| FaxNumber: | 7574465196 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2006 | ||||||||
| LastUpdateDate: | 01/23/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0101036347 | VA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QG0300X | 0101036347 | VA | Y | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | PAR | 01 | VA | VIRGINIA PREMIER HEALTH | OTHER | 005612632 | 05 | VA | MEDICAID | 0526K | 01 | NC | BC/BS | OTHER | 081925 | 01 | VA | ANTHEM | OTHER | PAR | 01 | VA | MULTIPLAN | OTHER | 11025 | 01 | VA | SENTARA OPTIMA | OTHER | 890526K | 05 | NC | MEDICAID | PAR | 01 | VA | CORVEL/CORCARE | OTHER | 005624151 | 05 | VA | MEDICAID | PAR | 01 | VA | VA HEALTH NETWORK | OTHER | PAR | 01 | VA | FIRST HEATLH COMMERCIAL/SOUTHERN HEALTH/COVENTRY | OTHER | -002 -003 | 01 | VA | TRICARE/CHAMPUS | OTHER | 2180424 | 01 | VA | UHC/MAMSI | OTHER | PAR | 01 | VA | CIGNA | OTHER | PAR | 01 | VA | AETNA | OTHER | PAR | 01 | VA | USA MANAGED CARE | OTHER |