Provider Demographics
NPI:1962721761
Name:EDMUND G GRANT MD PA
Entity type:Organization
Organization Name:EDMUND G GRANT MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDMUND
Authorized Official - Middle Name:GUY
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:813-971-8811
Mailing Address - Street 1:13801 BRUCE B DOWNS BLVD
Mailing Address - Street 2:SUITE 401
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-3946
Mailing Address - Country:US
Mailing Address - Phone:813-971-8811
Mailing Address - Fax:813-971-6951
Practice Address - Street 1:13801 BRUCE B DOWNS BLVD
Practice Address - Street 2:SUITE 401
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-3946
Practice Address - Country:US
Practice Address - Phone:813-971-8811
Practice Address - Fax:813-971-6951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-19
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00373502084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL068668900Medicaid
FL068668900Medicaid
FLDC940AMedicare PIN