Provider Demographics
NPI:1104321454
Name:GRANT, AUSTIN MARC BURNS (MD)
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:MARC BURNS
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 1:473 MURPHY RD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8143
Mailing Address - Country:US
Mailing Address - Phone:541-773-1165
Mailing Address - Fax:
Practice Address - Street 1:473 MURPHY RD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8143
Practice Address - Country:US
Practice Address - Phone:541-772-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-28
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ORMD212403208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program