Healthcare Provider Details

I. General information

NPI: 1962490128
Provider Name (Legal Business Name): BRYDON J.B. GRANT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 03/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10712 S 1300 E
SANDY UT
84094-5094
US

IV. Provider business mailing address

205 BAYNES CT
CHAPEL HILL NC
27517-9523
US

V. Phone/Fax

Practice location:
  • Phone: 800-258-5329
  • Fax:
Mailing address:
  • Phone: 919-419-0125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number5868721-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number154772
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: