Healthcare Provider Details

I. General information

NPI: 1003994203
Provider Name (Legal Business Name): SUSAN L GRANT M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 01/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

490 WEST END AVE APT 12-B
NEW YORK NY
10024
US

IV. Provider business mailing address

490 WEST END AVE APT 12-B
NEW YORK NY
10024
US

V. Phone/Fax

Practice location:
  • Phone: 917-715-2600
  • Fax: 212-769-4728
Mailing address:
  • Phone: 917-715-2600
  • Fax: 212-769-4728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberNYS143686
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: