Provider Demographics
NPI:1134140304
Name:GRANGER, MARK JOSEPH (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JOSEPH
Last Name:GRANGER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1908 FLINT RD SE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-6031
Mailing Address - Country:US
Mailing Address - Phone:256-340-9708
Mailing Address - Fax:256-340-9624
Practice Address - Street 1:4223 ORANGE BEACH BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:ORANGE BEACH
Practice Address - State:AL
Practice Address - Zip Code:36561-3459
Practice Address - Country:US
Practice Address - Phone:251-981-1300
Practice Address - Fax:251-981-1305
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2009-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH3635225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1003819608OtherGROUP NPI
AL510-02352OtherBCBS
AL890015200Medicaid
ALDB9027OtherRAILROAD MEDICARE GROUP
AL051556329Medicare UPIN
AL890015200Medicaid