Provider Demographics
NPI:1255565313
Name:GRANVILLE HEALTH INC
Entity type:Organization
Organization Name:GRANVILLE HEALTH INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GEORGEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:ERTISCHEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-690-3280
Mailing Address - Street 1:PO BOX 986
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27565-0986
Mailing Address - Country:US
Mailing Address - Phone:919-690-8880
Mailing Address - Fax:919-690-8882
Practice Address - Street 1:100 DURHAM STREET
Practice Address - Street 2:
Practice Address - City:STOVALL
Practice Address - State:NC
Practice Address - Zip Code:27582
Practice Address - Country:US
Practice Address - Phone:919-690-8880
Practice Address - Fax:919-690-8882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-05
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5912213Medicaid
NC2347346BMedicare PIN