Provider Demographics
NPI:1902112253
Name:GRANT, MICHAEL EDWARD (MD,PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:EDWARD
Last Name:GRANT
Suffix:
Gender:M
Credentials:MD,PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3890 PHEASANT RIDGE DR NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-5854
Mailing Address - Country:US
Mailing Address - Phone:763-792-9507
Mailing Address - Fax:763-792-9514
Practice Address - Street 1:3890 PHEASANT RIDGE DR NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-5854
Practice Address - Country:US
Practice Address - Phone:763-792-9507
Practice Address - Fax:763-792-9514
Is Sole Proprietor?:No
Enumeration Date:2010-08-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN502209174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN502209OtherBOARD OF PHARMANCY LICENSE
MN502209OtherBOARD OF PHARMANCY LICENSE