Healthcare Provider Details

I. General information

NPI: 1437356326
Provider Name (Legal Business Name): BRIAN W GRANTHAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2007
Last Update Date: 09/25/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4430 MISSOURI AVE
FORT LEONARD WOOD MO
65473-9098
US

IV. Provider business mailing address

4430 MISSOURI AVE
FORT LEONARD WOOD MO
65473-9098
US

V. Phone/Fax

Practice location:
  • Phone: 573-596-0417
  • Fax:
Mailing address:
  • Phone: 573-596-0417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberE998
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code2083S0010X
TaxonomySports Medicine (Preventive Medicine) Physician
License NumberE998
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberE998
License Number StateAR
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberE998
License Number StateAR
# 5
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberE998
License Number StateAR
# 6
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberE998
License Number StateAR
# 7
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2017026692
License Number StateMO
# 8
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE998
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: