Provider Demographics
NPI:1750797064
Name:GRANGER, MATTHEW
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:GRANGER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:473 W 12TH AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43210-1252
Mailing Address - Country:US
Mailing Address - Phone:614-293-7677
Mailing Address - Fax:
Practice Address - Street 1:800 E BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-1015
Practice Address - Country:US
Practice Address - Phone:614-252-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-08
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.15907-NP363LF0000X
OH15907CNP207RA0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0002XAllopathic & Osteopathic PhysiciansInternal MedicineAdult Congenital Heart Disease
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily