Healthcare Provider Details

I. General information

NPI: 1922120112
Provider Name (Legal Business Name): GRANT C SHIRLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 PHILADELPHIA DR
DAYTON OH
45406-1813
US

IV. Provider business mailing address

78 WAKEFIELD DR NE
ATLANTA GA
30309-1515
US

V. Phone/Fax

Practice location:
  • Phone: 937-775-1400
  • Fax:
Mailing address:
  • Phone: 678-596-9656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number89367
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: