Healthcare Provider Details

I. General information

NPI: 1558767640
Provider Name (Legal Business Name): GRANT BROOKS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2014
Last Update Date: 11/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 S PARK ST
MADISON WI
53715-1507
US

IV. Provider business mailing address

202 S PARK ST MERITER HOSPITAL, INC
MADISON WI
53715-1507
US

V. Phone/Fax

Practice location:
  • Phone: 608-417-6000
  • Fax:
Mailing address:
  • Phone: 608-417-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number225400000
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: