Provider Demographics
NPI:1013414721
Name:GRANRUD, MARC OLAV
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:OLAV
Last Name:GRANRUD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2003 KOOTENAI HEALTH WAY
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-6051
Mailing Address - Country:US
Mailing Address - Phone:208-625-6900
Mailing Address - Fax:208-625-6910
Practice Address - Street 1:2003 KOOTENAI HEALTH WAY
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-6051
Practice Address - Country:US
Practice Address - Phone:208-625-6900
Practice Address - Fax:208-625-6710
Is Sole Proprietor?:No
Enumeration Date:2018-04-09
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN29289207R00000X
MN65851207R00000X
IDM-15879208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine