Provider Demographics
NPI:1104292150
Name:GRANT, LARS (MD)
Entity type:Individual
Prefix:
First Name:LARS
Middle Name:
Last Name:GRANT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 W PARK ST
Mailing Address - Street 2:EMERGENCY DEPARTMENT
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2334
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 W PARK ST
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2334
Practice Address - Country:US
Practice Address - Phone:217-337-2131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-13
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036138607207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine