Healthcare Provider Details

I. General information

NPI: 1134651599
Provider Name (Legal Business Name): GRANT W MCKENZIE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2017
Last Update Date: 06/12/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 SILAS CREEK PKWY
WINSTON SALEM NC
27103-3013
US

IV. Provider business mailing address

200 QUEENS RD STE 400
CHARLOTTE NC
28204-3264
US

V. Phone/Fax

Practice location:
  • Phone: 336-718-3013
  • Fax:
Mailing address:
  • Phone: 704-765-2578
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0203X
TaxonomyTherapeutic Radiology Physician
License NumberR5143
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number2024-00919
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: