Healthcare Provider Details

I. General information

NPI: 1104454909
Provider Name (Legal Business Name): GRANT LIBRA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2020
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 W 57TH ST FL 15
NEW YORK NY
10107-1307
US

IV. Provider business mailing address

6201 GREENLEIGH AVE
MIDDLE RIVER MD
21220-2004
US

V. Phone/Fax

Practice location:
  • Phone: 816-853-8852
  • Fax:
Mailing address:
  • Phone: 410-933-0000
  • Fax: 410-500-4266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberD0105001
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD600004354
License Number StateDC
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number320882
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: