=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962497677
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GARRY D GRANT MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2005
-----------------------------------------------------
Last Update Date | 11/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2055 MUD CREEK RD
-----------------------------------------------------
City | EUREKA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59917-9070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-424-2020
-----------------------------------------------------
Fax | 812-424-3000
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2450
-----------------------------------------------------
City | EUREKA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59917-2450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-204-1703
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207WX0107X
-----------------------------------------------------
Taxonomy Name | Retina Specialist (Ophthalmology) Physician
-----------------------------------------------------
License Number | MED-PHYS-LIC-57501
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------