Provider Demographics
NPI:1194766949
Name:EISELEN, GRANT K (MD)
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:K
Last Name:EISELEN
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:PO BOX 25471
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14625-0471
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:27 HUNTINGTON BRK
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14625-1810
Practice Address - Country:US
Practice Address - Phone:585-261-3404
Practice Address - Fax:585-261-3404
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK57422085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD6778Medicaid
AKK160468Medicare ID - Type Unspecified
AKI46119Medicare UPIN