Basic Information
| Provider Information | |||||||||
| NPI: | 1841483732 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PETER GRANT MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2640 E BARNETT RD | ||||||||
| Address2: | SUITE E #225 | ||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975044301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418424404 | ||||||||
| FaxNumber: | 5417721048 | ||||||||
| Practice Location | |||||||||
| Address1: | 635 LASSEN LN | ||||||||
| Address2: | |||||||||
| City: | MOUNT SHASTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960679003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5309265211 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2007 | ||||||||
| LastUpdateDate: | 08/23/2007 | ||||||||
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| AuthorizedOfficialLastName: | GRANT | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | SOLO PRACTITIONER | ||||||||
| AuthorizedOfficialTelephone: | 5309265211 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | C43023 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.