Provider Demographics
NPI:1851338347
Name:GRANKE, KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:GRANKE
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 1:4967 CROOKS RD
Mailing Address - Street 2:STE 130
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098-5801
Mailing Address - Country:US
Mailing Address - Phone:248-952-1601
Mailing Address - Fax:248-952-1614
Practice Address - Street 1:2104 E 11 MILE RD
Practice Address - Street 2:SUITE 600
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48091-6122
Practice Address - Country:US
Practice Address - Phone:734-464-0887
Practice Address - Fax:734-402-0254
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010462902086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1851338347Medicaid
MIC36179048Medicare PIN