Provider Demographics
NPI:1316948649
Name:GRANT FAMILY MEDICINE, LLC
Entity type:Organization
Organization Name:GRANT FAMILY MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HILDA
Authorized Official - Middle Name:BERNICE
Authorized Official - Last Name:CRAZE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-728-8600
Mailing Address - Street 1:4500 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GRANT
Mailing Address - State:AL
Mailing Address - Zip Code:35747-8303
Mailing Address - Country:US
Mailing Address - Phone:256-728-8600
Mailing Address - Fax:256-728-8602
Practice Address - Street 1:4500 MAIN ST
Practice Address - Street 2:
Practice Address - City:GRANT
Practice Address - State:AL
Practice Address - Zip Code:35747-8303
Practice Address - Country:US
Practice Address - Phone:256-728-8600
Practice Address - Fax:256-728-8602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12795261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL404999OtherAETNA
AL51000192OtherBLUE CROSS BLUE SHIELD
AL404999OtherAETNA