Provider Demographics
NPI:1124018866
Name:GRANGER, TOMMIE MACK (MD)
Entity Type:Individual
Prefix:DR
First Name:TOMMIE
Middle Name:MACK
Last Name:GRANGER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 4TH ST
Mailing Address - Street 2:BOX 30163
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-8421
Mailing Address - Country:US
Mailing Address - Phone:318-767-5878
Mailing Address - Fax:318-767-5887
Practice Address - Street 1:211 4TH ST
Practice Address - Street 2:BOX 30163
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-8421
Practice Address - Country:US
Practice Address - Phone:318-767-5878
Practice Address - Fax:318-767-5887
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-25
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10146R208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MP126445OtherMISSISSIPPI MEDICAID
LA1982067Medicaid
MP126445OtherMISSISSIPPI MEDICAID
F73521Medicare UPIN
020052545Medicare PIN