Healthcare Provider Details

I. General information

NPI: 1245236744
Provider Name (Legal Business Name): EDWARD KEITH GRANT P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 02/07/2025
Certification Date: 02/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N MACON ST
MACON GA
31210-6563
US

IV. Provider business mailing address

PO BOX 370
FORTSON GA
31808-0370
US

V. Phone/Fax

Practice location:
  • Phone: 478-200-6970
  • Fax:
Mailing address:
  • Phone: 706-494-3171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number004120
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number4120
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: