Healthcare Provider Details

I. General information

NPI: 1356481790
Provider Name (Legal Business Name): GRANT B BELNAP MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 06/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1032 S BRIDGE WAY PL SUITE 100
EAGLE ID
83616-6099
US

IV. Provider business mailing address

1032 S BRIDGEWAY PLACE SUITE 100
EAGLE ID
83616
US

V. Phone/Fax

Practice location:
  • Phone: 208-246-0123
  • Fax: 208-246-0125
Mailing address:
  • Phone: 208-246-0123
  • Fax: 208-246-0125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberM7357
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberM7357
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License NumberM7357
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: