MEDICARE: GRANT NH LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1245484427
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRANT NH LLC

Provider Business Mailing Address
First Line	:	814 NORTHWOOD PARK DR
Second Line	:
City	:	VALDOSTA
State	:	GA
Zip	:	31602-1398
Country	:	US
Telephone Number	:	229-259-0032
Fax Number	:

Provider Business Practice Location Address
First Line	:	814 NORTHWOOD PARK DR
Second Line	:
City	:	VALDOSTA
State	:	GA
Zip	:	31602-1398
Country	:	US
Telephone Number	:	229-259-0032
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	DR. DOUGLAS MOSS
Credential	:	MD
Telephone Number	:	229-259-0032

Provider Enumeration Date	:	11/14/2008
Last Update Date	:	01/05/2012

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Directions to “GRANT NH LLC ” Practice Location

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