MEDICARE: GRANTLEY JOSEPH M.D.

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	039376	GA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	110121708	OTHER		RAIL ROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	5492108	OTHER	AETNA
4	658015	OTHER	BLUE CROSS BLUE SHIELDS

General Provider Information

NPI Number	:	1861506016
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRANTLEY JOSEPH M.D.

Provider Business Mailing Address
First Line	:	PO BOX 934915
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	31193-4915
Country	:	US
Telephone Number	:	404-501-7969
Fax Number	:	404-501-3874

Provider Business Practice Location Address
First Line	:	4153B FLAT SHOALS PKWY
Second Line	:	STE 200
City	:	DECATUR
State	:	GA
Zip	:	30034-4189
Country	:	US
Telephone Number	:	404-585-5049
Fax Number	:	404-591-0292

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

Provider Enumeration Date	:	08/17/2006
Last Update Date	:	11/25/2014

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Directions to “ GRANTLEY JOSEPH M.D.” Practice Location

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