Provider Demographics
NPI:1356425672
Name:GRANGER MEDICAL CLINIC PC
Entity type:Organization
Organization Name:GRANGER MEDICAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:PENNINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-965-3600
Mailing Address - Street 1:3725 W 4100 S
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84120-5530
Mailing Address - Country:US
Mailing Address - Phone:801-965-3600
Mailing Address - Fax:
Practice Address - Street 1:348 E 4500 S
Practice Address - Street 2:SUITE 200
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-3906
Practice Address - Country:US
Practice Address - Phone:801-262-9800
Practice Address - Fax:801-262-8300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT164813-1205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000057755Medicare ID - Type Unspecified