Basic Information
| Provider Information | |||||||||
| NPI: | 1194765826 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRANT | ||||||||
| FirstName: | AUDREY | ||||||||
| MiddleName: | LOUISE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 634706 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452630001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8652923000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3636 HIGH ST | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 237073236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573982200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 11/07/2007 | ||||||||
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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 | 207P00000X | 0101043829 | VA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 139PJ | 01 | NC | BLUE CROSS | OTHER | P00247878 | 01 | VA | RAILROAD MEDICARE | OTHER | 64315286 | 05 | KY | MEDICAID | 5900979 | 05 | NC | MEDICAID | P00328958 | 01 | NC | RAILROAD MEDICARE | OTHER | 1194765826 | 05 | VA | MEDICAID | 170709 | 05 | SC | MEDICAID |