Basic Information
Provider Information | |||||||||
NPI: | 1518977917 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GRANT | ||||||||
FirstName: | ERIC | ||||||||
MiddleName: | H | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1650 COCHRANE CIR UNIT MEDDAC | ||||||||
Address2: |   | ||||||||
City: | FORT CARSON | ||||||||
State: | CO | ||||||||
PostalCode: | 809134604 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7195267172 | ||||||||
FaxNumber: | 7195267850 | ||||||||
Practice Location | |||||||||
Address1: | 1650 COCHRANE CIR UNIT MEDDAC | ||||||||
Address2: |   | ||||||||
City: | FORT CARSON | ||||||||
State: | CO | ||||||||
PostalCode: | 809134604 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7195267172 | ||||||||
FaxNumber: | 7195267850 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/08/2006 | ||||||||
LastUpdateDate: | 11/12/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/12/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 969 | NV | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | 002018431 | 05 | NV |   | MEDICAID |