Provider Demographics
NPI:1164483046
Name:GRANGER, BRUCE TODD (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:TODD
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 1:11312 US 15 501 N
Mailing Address - Street 2:SUITE 106
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27517-6375
Mailing Address - Country:US
Mailing Address - Phone:919-533-4686
Mailing Address - Fax:
Practice Address - Street 1:11312 US 15 501 N
Practice Address - Street 2:SUITE 106
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27517-6375
Practice Address - Country:US
Practice Address - Phone:919-533-4686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-30
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC36189207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7936725Medicaid
110079482OtherRAILROAD RETIRE
NC2186690CMedicare PIN
NC7936725Medicaid
NC2186690Medicare PIN
NC7936725Medicaid