Provider Demographics
NPI:1265527998
Name:GRANGER, MIGUEL H (MD)
Entity type:Individual
Prefix:DR
First Name:MIGUEL
Middle Name:H
Last Name:GRANGER
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 1:2001 STATE ST
Mailing Address - Street 2:
Mailing Address - City:EAST SAINT LOUIS
Mailing Address - State:IL
Mailing Address - Zip Code:62205-1803
Mailing Address - Country:US
Mailing Address - Phone:618-271-9191
Mailing Address - Fax:618-271-9617
Practice Address - Street 1:2001 STATE ST
Practice Address - Street 2:
Practice Address - City:EAST SAINT LOUIS
Practice Address - State:IL
Practice Address - Zip Code:62205-1803
Practice Address - Country:US
Practice Address - Phone:618-271-9191
Practice Address - Fax:618-271-9617
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036106215207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036103215Medicaid
ILL80157Medicare ID - Type Unspecified
ILH23232Medicare UPIN