Healthcare Provider Details

I. General information

NPI: 1932140456
Provider Name (Legal Business Name): DALE COURTNEY GRANTHAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 05/30/2023
Certification Date: 05/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 BLUE SAGE RD NE
RIO RANCHO NM
87144-5763
US

IV. Provider business mailing address

3129 N 109TH TER
KANSAS CITY KS
66109-8901
US

V. Phone/Fax

Practice location:
  • Phone: 509-942-4793
  • Fax:
Mailing address:
  • Phone: 509-942-4793
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD00041473
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD2012-0049193
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberMD2012-0049193
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: