Basic Information
| Provider Information | |||||||||
| NPI: | 1639261035 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRANT | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | CHRISTIAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4602 DEPT | ||||||||
| Address2: | |||||||||
| City: | CAROL STREAM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601220021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9062254821 | ||||||||
| FaxNumber: | 9062254537 | ||||||||
| Practice Location | |||||||||
| Address1: | 420 W MAGNETIC ST | ||||||||
| Address2: | |||||||||
| City: | MARQUETTE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498552711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9062253561 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2006 | ||||||||
| LastUpdateDate: | 04/28/2009 | ||||||||
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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 | 207P00000X | MD25662 | OR | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 208D00000X | 4301089202 | MI | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | P00456632 | 01 | MI | RAILROAD MEDICARE | OTHER | DG089202 | 01 | MI | BLUE CROSS | OTHER | 5212533 | 05 | MI | MEDICAID |