Healthcare Provider Details

I. General information

NPI: 1235666298
Provider Name (Legal Business Name): GRANT HERRON MOODY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2017
Last Update Date: 07/12/2023
Certification Date: 07/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 NORTHSIDE CHEROKEE BLVD
CANTON GA
30115-8015
US

IV. Provider business mailing address

450 NORTHSIDE CHEROKEE BLVD
CANTON GA
30115-8015
US

V. Phone/Fax

Practice location:
  • Phone: 770-224-1000
  • Fax: 770-224-2451
Mailing address:
  • Phone: 770-224-1000
  • Fax: 770-224-2451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number38192
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number95843
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: