Provider Demographics
NPI:1285043596
Name:GRANGER MEDICAL SLEEP CLINIC
Entity Type:Organization
Organization Name:GRANGER MEDICAL SLEEP CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-965-3505
Mailing Address - Street 1:3181 W 9000 S
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-5610
Mailing Address - Country:US
Mailing Address - Phone:801-352-5950
Mailing Address - Fax:801-352-5550
Practice Address - Street 1:3181 W 9000 S
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-5610
Practice Address - Country:US
Practice Address - Phone:801-352-5950
Practice Address - Fax:801-352-5550
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRANGER MEDICAL CLINIC, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-08-12
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5139563-1205207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000004880Medicare PIN