Healthcare Provider Details

I. General information

NPI: 1639639669
Provider Name (Legal Business Name): JACOB CARLOS EARL GRANT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2019
Last Update Date: 07/14/2025
Certification Date: 07/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 S KINGSHIGHWAY BLVD DEPT RADIOLOGY
SAINT LOUIS MO
63110-1016
US

IV. Provider business mailing address

9998 CROSSPOINT BLVD STE 200
INDIANAPOLIS IN
46256-3307
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-7200
  • Fax: 314-747-4189
Mailing address:
  • Phone: 317-579-2150
  • Fax: 317-806-8296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number01095875A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: