Provider Demographics
NPI:1215303110
Name:GRANT, BRIAN MICHAEL (MB, BS)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:MICHAEL
Last Name:GRANT
Suffix:
Gender:M
Credentials:MB, BS
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 2697
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42102-7697
Mailing Address - Country:US
Mailing Address - Phone:270-745-1100
Mailing Address - Fax:270-745-1156
Practice Address - Street 1:825 2ND AVE STE B1
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-1790
Practice Address - Country:US
Practice Address - Phone:270-796-3330
Practice Address - Fax:270-796-3338
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-13
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMTL002969390200000X
KY563462086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty