Healthcare Provider Details

I. General information

NPI: 1720407299
Provider Name (Legal Business Name): ALEXANDER GRANT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2014
Last Update Date: 02/11/2020
Certification Date: 02/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W MAIN ST STE 16
WYCKOFF NJ
07481-1406
US

IV. Provider business mailing address

16 GROVE AVE
CEDAR GROVE NJ
07009-1452
US

V. Phone/Fax

Practice location:
  • Phone: 201-847-9320
  • Fax: 201-847-0059
Mailing address:
  • Phone: 401-714-7972
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number25MA10348500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: