Provider Demographics
NPI:1366745705
Name:JERRY H GRANT, M.D., P.A.
Entity type:Organization
Organization Name:JERRY H GRANT, M.D., P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-862-2285
Mailing Address - Street 1:104 E GROVE ST
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:AR
Mailing Address - Zip Code:71730-4607
Mailing Address - Country:US
Mailing Address - Phone:870-862-2285
Mailing Address - Fax:870-862-2289
Practice Address - Street 1:104 E GROVE ST
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:AR
Practice Address - Zip Code:71730
Practice Address - Country:US
Practice Address - Phone:870-862-2285
Practice Address - Fax:870-862-2289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-07
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-0952261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR130237001Medicaid
AR080128979OtherRAILROAD MEDICARE
AR130237001Medicaid