Provider Demographics
NPI:1629069034
Name:GRANGER, GLYNN ADAM (MD)
Entity Type:Individual
Prefix:DR
First Name:GLYNN
Middle Name:ADAM
Last Name:GRANGER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3975 I 49 S SERVICE RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:OPELOUSAS
Mailing Address - State:LA
Mailing Address - Zip Code:70570-0775
Mailing Address - Country:US
Mailing Address - Phone:337-948-7680
Mailing Address - Fax:337-948-1143
Practice Address - Street 1:3975 I 49 S SERVICE RD
Practice Address - Street 2:SUITE 105
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570-0775
Practice Address - Country:US
Practice Address - Phone:337-948-7680
Practice Address - Fax:337-948-1143
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA011393208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1134643Medicaid
LA52229Medicare PIN