Basic Information
| Provider Information | |||||||||
| NPI: | 1740239581 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAMMONS | ||||||||
| FirstName: | GRANT | ||||||||
| MiddleName: | VICTOR | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 E 14TH ST | ||||||||
| Address2: | |||||||||
| City: | SEDALIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 653015972 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6608279407 | ||||||||
| FaxNumber: | 6608273742 | ||||||||
| Practice Location | |||||||||
| Address1: | 3700 W 10TH ST | ||||||||
| Address2: | STE: 301 | ||||||||
| City: | SEDALIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 653012540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6608272730 | ||||||||
| FaxNumber: | 6608272731 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2006 | ||||||||
| LastUpdateDate: | 03/26/2015 | ||||||||
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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 | 207R00000X | 2001012643 | MO | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 2008034889 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000096276 | 01 | MO | BCBS | OTHER |