Healthcare Provider Details

I. General information

NPI: 1144299413
Provider Name (Legal Business Name): WILLIAM MARK GRANT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 07/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 E BROADWAY SUITE 300
COLUMBIA MO
65201-7166
US

IV. Provider business mailing address

1705 E BROADWAY SUITE 300
COLUMBIA MO
65201-7166
US

V. Phone/Fax

Practice location:
  • Phone: 573-817-0810
  • Fax: 573-817-1790
Mailing address:
  • Phone: 573-817-0810
  • Fax: 573-817-1790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberR2H91
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License NumberR2H91
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: