Healthcare Provider Details

I. General information

NPI: 1356655781
Provider Name (Legal Business Name): GRANT WILLIAM EYJOLFSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2010
Last Update Date: 07/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 SOUTH COLUMBIA ROAD
GRAND FORKS ND
58206-6002
US

IV. Provider business mailing address

501 E. LINCOLN ST. PO BOX 106
HENDRICKS MN
56136
US

V. Phone/Fax

Practice location:
  • Phone: 701-780-5000
  • Fax: 701-780-6860
Mailing address:
  • Phone: 507-275-3121
  • Fax: 507-275-3194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number56053
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberRL11611
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: