MEDICARE: ROY N GRANTHAM MD

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	2086S0129X	Vascular Surgery Physician	16465	OK

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	060052653	OTHER		RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5765290	OTHER	OK	AETNA
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	125309100	OTHER	OK	DOL

General Provider Information

NPI Number	:	1568457265
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROY N GRANTHAM MD

Provider Business Mailing Address
First Line	:	3545 NW 58TH ST
Second Line	:	450
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-4726
Country	:	US
Telephone Number	:	405-951-4360
Fax Number	:	866-857-2543

Provider Business Practice Location Address
First Line	:	4221 S WESTERN AVE
Second Line	:	2010
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73109-3447
Country	:	US
Telephone Number	:	405-231-0540
Fax Number	:	405-644-5309

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/19/2005
Last Update Date	:	12/04/2014

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Directions to “ ROY N GRANTHAM MD” Practice Location

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