Provider Demographics
NPI:1467872739
Name:GRANATI, GLEN THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:THOMAS
Last Name:GRANATI
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:MATHER HOSPITAL, 75 NORTH COUNTRY RD
Mailing Address - Street 2:INTENSIVIST DEPARTMENT
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777
Mailing Address - Country:US
Mailing Address - Phone:631-473-1320
Mailing Address - Fax:
Practice Address - Street 1:MATHER HOSPITAL, 75 N COUNTRY RD
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777
Practice Address - Country:US
Practice Address - Phone:631-473-1320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-24
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY302485207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease