Healthcare Provider Details

I. General information

NPI: 1225079510
Provider Name (Legal Business Name): MARK GRANT D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16001 W 9 MILE RD
SOUTHFIELD MI
48075-4818
US

IV. Provider business mailing address

8986 DEER TRL
BRIGHTON MI
48114-7567
US

V. Phone/Fax

Practice location:
  • Phone: 248-849-3000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number5101011024
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: