Provider Demographics
NPI:1073701462
Name:NILES ORTHOPEDICS, P.C.
Entity Type:Organization
Organization Name:NILES ORTHOPEDICS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:GRANNELL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:269-684-3028
Mailing Address - Street 1:6 LONGMEADOW VILLAGE DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-7810
Mailing Address - Country:US
Mailing Address - Phone:269-684-3028
Mailing Address - Fax:268-684-5291
Practice Address - Street 1:6 LONGMEADOW VILLAGE DR
Practice Address - Street 2:SUITE 1
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-7810
Practice Address - Country:US
Practice Address - Phone:269-684-3028
Practice Address - Fax:268-684-5291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-10
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101007545207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1575040Medicaid
A74802Medicare UPIN
MI1575040Medicaid