MEDICARE: MARC B GRANT DO

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	207LP2900X	Pain Medicine (Anesthesiology) Physician	1609	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	H20777190	OTHER	AZ	BXBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1700857125
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARC B GRANT DO

Provider Business Mailing Address
First Line	:	708 S COEUR D ALENE LN
Second Line	:
City	:	PAYSON
State	:	AZ
Zip	:	85541-5662
Country	:	US
Telephone Number	:	928-468-1337
Fax Number	:	928-468-1339

Provider Business Practice Location Address
First Line	:	708 S COEUR D ALENE LN
Second Line	:
City	:	PAYSON
State	:	AZ
Zip	:	85541-5662
Country	:	US
Telephone Number	:	928-468-1337
Fax Number	:	928-468-1339

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

Provider Enumeration Date	:	02/01/2006
Last Update Date	:	09/15/2012

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Directions to “ MARC B GRANT DO” Practice Location

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