1033557459 NPI number — COURTNEY L GRANT M.D.

Table of content: COURTNEY L GRANT M.D. (NPI 1033557459)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033557459 NPI number — COURTNEY L GRANT M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRANT
Provider First Name:
COURTNEY
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033557459
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/07/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 742616
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30374-2616
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
725 JESSE JEWELL PKWY SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GAINESVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30501-3834
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-207-4000
Provider Business Practice Location Address Fax Number:
770-531-2435
Provider Enumeration Date:
06/07/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  0116025753 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: 86237 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0129X , with the licence number: 86237 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 003235364G , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003235364D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003235364B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003235364C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003235364F , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003235364H , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003235364A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003235364E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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