Provider Demographics
NPI:1881655652
Name:GRANOVSKY, MICHAEL A (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:GRANOVSKY
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:PO BOX 500
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:VA
Mailing Address - Zip Code:20116-0500
Mailing Address - Country:US
Mailing Address - Phone:301-686-9010
Mailing Address - Fax:
Practice Address - Street 1:11711 LIVINGSTON RD
Practice Address - Street 2:
Practice Address - City:FT WASHINGTON
Practice Address - State:MD
Practice Address - Zip Code:20744-5151
Practice Address - Country:US
Practice Address - Phone:301-203-2250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0046947207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD550300100Medicaid
DC017158500Medicaid
MD76881001OtherMARYLAND BLUE SHIELD
DCH9140003OtherDC BLUE SHIELD
MDG93435Medicare UPIN
MD000K71G47Medicare ID - Type UnspecifiedMCRE RENDERING