MEDICARE: SHAWN WILLIAM GRANT MS PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	5501011503	MI

General Provider Information

NPI Number	:	1487613899
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAWN WILLIAM GRANT MS PT

Provider Business Mailing Address
First Line	:	29822 S WIXOM RD
Second Line	:
City	:	WIXOM
State	:	MI
Zip	:	48393-3434
Country	:	US
Telephone Number	:	248-926-5826
Fax Number	:	248-926-5830

Provider Business Practice Location Address
First Line	:	29822 WIXOM RD.
Second Line	:
City	:	WIXOM
State	:	MI
Zip	:	48393
Country	:	US
Telephone Number	:	248-926-5826
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/23/2006
Last Update Date	:	07/08/2007

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