Basic Information
| Provider Information | |||||||||
| NPI: | 1528087988 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRANT | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5501 OLD YORK ROAD | ||||||||
| Address2: | WILLOWCREST 4TH FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154567900 | ||||||||
| FaxNumber: | 2154563428 | ||||||||
| Practice Location | |||||||||
| Address1: | 5501 OLD YORK RD | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191413018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154567900 | ||||||||
| FaxNumber: | 2154565948 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 03/08/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 35-052114 | OH | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | MD445476 | PA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 738057 | 01 | OH | BUCKEYE | OTHER | 000000503677 | 01 | OH | ANTHEM | OTHER | 000000221326 | 01 | OH | UNISON | OTHER | P00358792 | 01 | OH | RAILROAD MEDICARE | OTHER | 2610339 | 05 | OH | MEDICAID | 363580 | 01 | OH | WELLCARE | OTHER | 4311723 | 01 | OH | AETNA | OTHER |