Basic Information
| Provider Information | |||||||||
| NPI: | 1528441359 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRANT | ||||||||
| FirstName: | ELAINE | ||||||||
| MiddleName: | GENEVIEVE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BURGESS | ||||||||
| OtherFirstName: | ELAINE | ||||||||
| OtherMiddleName: | GENEVIEVE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DPM | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 32743 23 MILE RD | ||||||||
| Address2: | STE 210 | ||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480472176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867253444 | ||||||||
| FaxNumber: | 5867250984 | ||||||||
| Practice Location | |||||||||
| Address1: | 32743 23 MILE RD STE 110 | ||||||||
| Address2: | |||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867253444 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2015 | ||||||||
| LastUpdateDate: | 07/27/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 5901002582 | MI | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.