Basic Information
| Provider Information | |||||||||
| NPI: | 1982694717 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRANT | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | THOMAS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M D | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 550 ORCHARD PARK RD | ||||||||
| Address2: | BUILDING B, SUITE 105 | ||||||||
| City: | WEST SENECA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142242646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166776404 | ||||||||
| FaxNumber: | 7166776407 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 ORCHARD PARK RD | ||||||||
| Address2: | BUILDING B, SUITE 105 | ||||||||
| City: | WEST SENECA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142242646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166776404 | ||||||||
| FaxNumber: | 7166776407 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2005 | ||||||||
| LastUpdateDate: | 01/23/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 147528 | NY | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 00886879 | 05 | NY | MEDICAID | BB1860 | 01 | NY | MEDICARE | OTHER | 00010067501 | 01 | NY | UNIVERA | OTHER | 0902816 | 01 | NY | INDEPENDENT HEALTH | OTHER | AA0091 | 01 | MEDICARE LEGACY # | OTHER | 000500843001 | 01 | NY | BLUE CROSS | OTHER |