Healthcare Provider Details

I. General information

NPI: 1841483732
Provider Name (Legal Business Name): PETER GRANT MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2007
Last Update Date: 08/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

635 LASSEN LN
MOUNT SHASTA CA
96067-9003
US

IV. Provider business mailing address

2640 E BARNETT RD SUITE E #225
MEDFORD OR
97504-4301
US

V. Phone/Fax

Practice location:
  • Phone: 530-926-5211
  • Fax:
Mailing address:
  • Phone: 541-842-4404
  • Fax: 541-772-1048

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberC43023
License Number StateCA

VIII. Authorized Official

Name: DR. PETER A GRANT
Title or Position: SOLO PRACTITIONER
Credential: MD
Phone: 530-926-5211