Healthcare Provider Details

I. General information

NPI: 1700208808
Provider Name (Legal Business Name): GRANT HOSPITALISTS SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2014
Last Update Date: 07/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S 15TH ST
WORLAND WY
82401-3531
US

IV. Provider business mailing address

2622 DEER RUN DR
SOUTH WEBER UT
84405-9419
US

V. Phone/Fax

Practice location:
  • Phone: 702-453-3799
  • Fax: 702-453-5741
Mailing address:
  • Phone: 702-453-3799
  • Fax: 702-453-5741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number6367A
License Number StateWY

VIII. Authorized Official

Name: MICHAEL RAMIT GRANT
Title or Position: OWNER
Credential: M.D.
Phone: 801-564-1502