Healthcare Provider Details

I. General information

NPI: 1376565788
Provider Name (Legal Business Name): GEORGE R GRANT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 03/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 HEALTH CENTER DRIVE
MATTOON IL
61938-0372
US

IV. Provider business mailing address

320 E HIGHWAY 50
O FALLON IL
62269-2704
US

V. Phone/Fax

Practice location:
  • Phone: 217-258-2551
  • Fax: 217-258-2256
Mailing address:
  • Phone: 618-624-3368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2001022239
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: