Provider Demographics
NPI:1649541699
Name:GRANGER MEDICAL CLINIC, PC
Entity type:Organization
Organization Name:GRANGER MEDICAL CLINIC, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-965-3505
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:801-965-3505
Mailing Address - Fax:
Practice Address - Street 1:1288 W 12700 S
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065-6794
Practice Address - Country:US
Practice Address - Phone:801-253-3500
Practice Address - Fax:801-253-5859
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRANGER MEDICAL CLINIC, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-01-23
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTE30736Medicare UPIN