Provider Demographics
NPI:1629163746
Name:GRANGER MEDICAL CLINIC, INC.
Entity Type:Organization
Organization Name:GRANGER MEDICAL CLINIC, INC.
Other - Org Name:GRANGER MEDICAL CLINIC - WASATCH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:M
Authorized Official - Last Name:WHITAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-965-3505
Mailing Address - Street 1:1160 E 3900 S
Mailing Address - Street 2:SUITE 1000
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1202
Mailing Address - Country:US
Mailing Address - Phone:801-262-1771
Mailing Address - Fax:801-288-9101
Practice Address - Street 1:1160 E 3900 S
Practice Address - Street 2:SUITE 1000
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1202
Practice Address - Country:US
Practice Address - Phone:801-262-1771
Practice Address - Fax:801-288-9101
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRANGER MEDICAL CLINIC, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-04
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT870526286207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870526286OtherEIN
UT870526286OtherEIN
UT000055217Medicare PIN