Provider Demographics
NPI:1699722207
Name:COMNICK, GRANT D (DO)
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:D
Last Name:COMNICK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18101 LORAIN AVENUE CLEVELAND CLINIC - FAIRVIEW HOSPITA
Mailing Address - Street 2:EMERGENCY SERVICES
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44111-5612
Mailing Address - Country:US
Mailing Address - Phone:216-476-7312
Mailing Address - Fax:
Practice Address - Street 1:18101 LORAIN AVENUE CLEVELAND CLINIC - FAIRVIEW HOSPITA
Practice Address - Street 2:EMERGENCY SERVICES
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44111-5612
Practice Address - Country:US
Practice Address - Phone:216-476-7312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-28
Last Update Date:2018-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34003752C207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0865916Medicaid
OH942460636277OtherCARESOURCE
OHP00194513OtherMEDICARE TRAVELERS RR-GA
OHCO0705127Medicare ID - Type Unspecified
OH942460636277OtherCARESOURCE