Provider Demographics
NPI:1093974404
Name:GRANVILLE HEALTH SYSTEM
Entity Type:Organization
Organization Name:GRANVILLE HEALTH SYSTEM
Other - Org Name:GRANVILLE PHYSICIANS GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:WEST
Authorized Official - Last Name:MCCONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-690-3402
Mailing Address - Street 1:PO BOX 947
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27565-0947
Mailing Address - Country:US
Mailing Address - Phone:919-690-3000
Mailing Address - Fax:919-690-3457
Practice Address - Street 1:1010 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:NC
Practice Address - Zip Code:27565-2507
Practice Address - Country:US
Practice Address - Phone:919-690-3000
Practice Address - Fax:919-690-3457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-02
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC26406207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC07705OtherBLUE CROSS
NC5950159Medicaid
NC07705OtherBLUE CROSS