Healthcare Provider Details

I. General information

NPI: 1962497677
Provider Name (Legal Business Name): GARRY D GRANT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 11/18/2022
Certification Date: 11/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2055 MUD CREEK RD
EUREKA MT
59917-9070
US

IV. Provider business mailing address

PO BOX 2450
EUREKA MT
59917-2450
US

V. Phone/Fax

Practice location:
  • Phone: 812-424-2020
  • Fax: 812-424-3000
Mailing address:
  • Phone: 812-204-1703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License NumberMED-PHYS-LIC-57501
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: