Provider Demographics
NPI:1720101819
Name:PHYSICIANS FAMILY PRACTICE, CHTRD.
Entity Type:Organization
Organization Name:PHYSICIANS FAMILY PRACTICE, CHTRD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:SAMUEL
Authorized Official - Last Name:GRANITE
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FAAFP, CGM
Authorized Official - Phone:301-474-2141
Mailing Address - Street 1:115 CENTERWAY
Mailing Address - Street 2:
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-1836
Mailing Address - Country:US
Mailing Address - Phone:301-474-2141
Mailing Address - Fax:301-345-3874
Practice Address - Street 1:115 CENTERWAY
Practice Address - Street 2:
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-1836
Practice Address - Country:US
Practice Address - Phone:301-474-2141
Practice Address - Fax:301-345-3874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C62016Medicare UPIN
G00153Medicare PIN