Provider Demographics
NPI:1275638777
Name:GRANNAN, SUZANNE M (MD)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:M
Last Name:GRANNAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8150 OAKLANDON ROAD
Practice Address - Street 2:SUITE 130
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46236-9543
Practice Address - Country:US
Practice Address - Phone:317-621-1111
Practice Address - Fax:317-621-1110
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010574642080N0001X
IN01057464A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200453750Medicaid
INP01179052OtherRR MEDICARE PTAN
IN266180099Medicare PIN
INP01179052OtherRR MEDICARE PTAN
I06210Medicare UPIN