Provider Demographics
NPI:1982751921
Name:SIMMONS, GRANT PEGRAM (MD)
Entity type:Individual
Prefix:DR
First Name:GRANT
Middle Name:PEGRAM
Last Name:SIMMONS
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 1:400 BERYWOOD TRL NW STE B
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37312-5288
Mailing Address - Country:US
Mailing Address - Phone:423-472-3201
Mailing Address - Fax:423-476-4949
Practice Address - Street 1:400 BERYWOOD TRL NW STE B
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37312-5288
Practice Address - Country:US
Practice Address - Phone:423-472-3201
Practice Address - Fax:423-476-4949
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000045559208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00016605Medicaid
LA1148245Medicaid
TN54146Medicare PIN
LA54146Medicare PIN
LAB65090Medicare UPIN