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General NPI Number Information
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NPI Number | 1306032297
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Entity Type | Organization
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Legal Business Name | PETER GRANT, MD, LTD
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Dates
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Enumeration Date | 09/24/2007
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Last Update Date | 09/24/2007
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Provider Practice Location Address
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Address Line | 1011 LAKE ST SUITE 300
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City | OAK PARK
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State | IL
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Zip | 60301-1148
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Country | US
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Telephone | 708-524-1747
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Fax |
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Provider Business Mailing Address
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Address Line | 1131 LAKE ST #214
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City | OAK PARK
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State | IL
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Zip | 60301-1001
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Country | US
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Telephone | 708-524-1747
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. PETER JAMES GRANT
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Credential | MD
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Telephone | 708-524-1747
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 036108911
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License Number State | IL
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