MEDICARE: DR. DANA LANELL GRANT 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	208000000X	Pediatrics Physician	19338	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1881759702
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DANA LANELL GRANT M.D.

Provider Business Mailing Address
First Line	:	297 HIGHWAY 51 STE B
Second Line	:
City	:	RIDGELAND
State	:	MS
Zip	:	39157-3423
Country	:	US
Telephone Number	:	601-707-5381
Fax Number	:	601-707-5382

Provider Business Practice Location Address
First Line	:	1824 HOSPITAL DR
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39204-3410
Country	:	US
Telephone Number	:	601-346-4586
Fax Number	:	601-346-4587

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

Provider Enumeration Date	:	12/22/2006
Last Update Date	:	11/15/2011

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