Provider Demographics
NPI:1407890817
Name:GRANSON, MARC A (MD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:A
Last Name:GRANSON
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 1:801 OSTRUM ST
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18015-1000
Mailing Address - Country:US
Mailing Address - Phone:610-954-4646
Mailing Address - Fax:610-954-6450
Practice Address - Street 1:801 OSTRUM ST
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18015-1000
Practice Address - Country:US
Practice Address - Phone:610-954-4646
Practice Address - Fax:610-954-6450
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD027101E2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA00940604Medicaid
PA00940604Medicaid
PA111502Medicare PIN