Healthcare Provider Details

I. General information

NPI: 1922026533
Provider Name (Legal Business Name): RUSSELL J GRANT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 02/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72780 COUNTRY CLUB DR SUITE B 203
RANCHO MIRAGE CA
92270-4126
US

IV. Provider business mailing address

72780 COUNTRY CLUB DR SUITE B 203
RANCHO MIRAGE CA
92270-4126
US

V. Phone/Fax

Practice location:
  • Phone: 760-674-3847
  • Fax: 760-674-3845
Mailing address:
  • Phone: 760-674-3847
  • Fax: 760-674-3845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number64150
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: