Basic Information
| Provider Information | |||||||||
| NPI: | 1003801275 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRANTHAM | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 35100 | ||||||||
| Address2: | |||||||||
| City: | BILLINGS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 591075100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062382500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 620 S HAYNES AVE | ||||||||
| Address2: | |||||||||
| City: | MILES CITY | ||||||||
| State: | MT | ||||||||
| PostalCode: | 593014769 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062382500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2005 | ||||||||
| LastUpdateDate: | 12/03/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 7907 | MT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0080529 | 05 | MT | MEDICAID |