MEDICARE: DR. MICHAEL THOMAS GRANT M D

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	174400000X	Specialist	147528	NY

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	BB1860	OTHER	NY	MEDICARE
5	AA0091	OTHER		MEDICARE LEGACY #

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	00010067501	OTHER	NY	UNIVERA
4	0902816	OTHER	NY	INDEPENDENT HEALTH
6	000500843001	OTHER	NY	BLUE CROSS

General Provider Information

NPI Number	:	1982694717
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL THOMAS GRANT M D

Provider Business Mailing Address
First Line	:	550 ORCHARD PARK RD
Second Line	:	BUILDING B, SUITE 105
City	:	WEST SENECA
State	:	NY
Zip	:	14224-2646
Country	:	US
Telephone Number	:	716-677-6404
Fax Number	:	716-677-6407

Provider Business Practice Location Address
First Line	:	550 ORCHARD PARK RD
Second Line	:	BUILDING B, SUITE 105
City	:	WEST SENECA
State	:	NY
Zip	:	14224-2646
Country	:	US
Telephone Number	:	716-677-6404
Fax Number	:	716-677-6407

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

Provider Enumeration Date	:	10/24/2005
Last Update Date	:	01/23/2012

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