Provider Demographics
NPI:1396752770
Name:GRANT, ROBERT (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
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 1:1144 N ROAD ST STE 200
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-3473
Mailing Address - Country:US
Mailing Address - Phone:252-384-2360
Mailing Address - Fax:252-384-2359
Practice Address - Street 1:1144 N ROAD ST STE 200
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-3473
Practice Address - Country:US
Practice Address - Phone:252-384-2360
Practice Address - Fax:252-384-2359
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101250123207X00000X, 207XX0005X
KY26510207X00000X
NC2003-01234207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY200016599OtherRR MEDICARE
KY4229925OtherAETNA
KY000000048618OtherANTHEM BCBS
KY65939795Medicaid
KY000000048618OtherANTHEM BCBS
KY200016599OtherRR MEDICARE