Provider Demographics
NPI:1093713695
Name:GRANVILLE FAMILY MEDICINE PA
Entity Type:Organization
Organization Name:GRANVILLE FAMILY MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:MAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-693-7108
Mailing Address - Street 1:103 PROFESSIONAL PARK STE A
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27565-2581
Mailing Address - Country:US
Mailing Address - Phone:919-693-7108
Mailing Address - Fax:919-693-9245
Practice Address - Street 1:103 PROFESSIONAL PARK STE A
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:NC
Practice Address - Zip Code:27565-2581
Practice Address - Country:US
Practice Address - Phone:919-693-7108
Practice Address - Fax:919-693-9245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-08
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC25053207Q00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC343950AMedicaid
NC0171AOtherBCBSNC
NC343950CMedicaid
NC343950Medicare Oscar/Certification
NC0171AOtherBCBSNC
NC2804606Medicare ID - Type UnspecifiedCIGNA MEDICARE
NC343950AMedicaid