Healthcare Provider Details

I. General information

NPI: 1669033007
Provider Name (Legal Business Name): GRANT MERRITT MCGORY JR. IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2019
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3259 CATLIN AVE
QUANTICO VA
22134-5109
US

IV. Provider business mailing address

24164 BELLEAU AVE
QUANTICO VA
22134-5106
US

V. Phone/Fax

Practice location:
  • Phone: 703-432-0384
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: