Basic Information
Provider Information
NPI: 1033557459
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: GRANT
FirstName: COURTNEY
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
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OtherCredential:  
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Mailing Information
Address1: 2655 PROSPERITY AVE
Address2: 110
City: FAIRFAX
State: VA
PostalCode: 220314908
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 3300 GALLOWS RD
Address2: INOVA FAIRFAX HOSPITAL - DEPT OF SURGERY
City: FALLS CHURCH
State: VA
PostalCode: 220423307
CountryCode: US
TelephoneNumber: 7067262107
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/07/2013
LastUpdateDate: 06/07/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
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AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
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AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
208600000X0116025753VAY Allopathic & Osteopathic PhysiciansSurgery 

No ID Information.


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