Provider Demographics
NPI:1417963562
Name:GRANGE, GEORGE R III (PT)
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:R
Last Name:GRANGE
Suffix:III
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 1:8708 HEATHER RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20879-4629
Mailing Address - Country:US
Mailing Address - Phone:301-208-3540
Mailing Address - Fax:
Practice Address - Street 1:9909 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-6361
Practice Address - Country:US
Practice Address - Phone:240-864-6200
Practice Address - Fax:240-864-6209
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD20648174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist