Provider Demographics
NPI:1194765826
Name:GRANT, AUDREY LOUISE (MD)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:LOUISE
Last Name:GRANT
Suffix:
Gender:F
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:PO BOX 634706
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-0001
Mailing Address - Country:US
Mailing Address - Phone:865-292-3000
Mailing Address - Fax:
Practice Address - Street 1:3636 HIGH ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23707-3236
Practice Address - Country:US
Practice Address - Phone:757-398-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101043829207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC139PJOtherBLUE CROSS
VAP00247878OtherRAILROAD MEDICARE
KY64315286Medicaid
NC5900979Medicaid
NCP00328958OtherRAILROAD MEDICARE
VA1194765826Medicaid
SC170709Medicaid
NC5900979Medicaid
SCC891788165Medicare PIN
C89178Medicare UPIN
SC170709Medicaid
VA00W415S46Medicare PIN